Well, finally, Sarah has launch orders from all of her health care teams (cardiothoracic surgery, cardiology, infectious disease, vascular surgery, electrophysiologic cardiolgy [pacemaker]). Each of these teams will want to see Sarah as an outpatient at various intervals in the coming months; some of them will want to do this "forever." We are hoping that occasionally these appointments can be arranged to occur on the same day.
Then there are the new teams that will need to become involved in addition to Sarah's primary care medical home - Critical Care Systems, which is the vendor that will provide all of the equipment needed to maintain Sarah's PICC line and assure that she can receive an IV dose of penicillin every 4 hours around the clock for 8 weeks; the Concord Regional Visiting Nurse Association, which will provide for all of the necessary blood draws for lab work and change the dressing on her PICC line (a sterile procedure); the Cardiac Rehabilitation Program at Concord Hospital to work on regaining strength and mobility; the local pharmacy for Sarah medication prescriptions.
What is about to unfold is known in the health systems research literature as a "transition of care." Sounds simple enough, and it must happen thousands of times a day in this country. However, our health care system is notorious for handling this poorly. Poor transitions to home care constitute one of the leading reasons for avoidable readmissions to the hospital. Good transitions require the ingredient that the Institute of Medicine says is most lacking in US health care - care coordination. We are about to find out if DHMC and the Concord health care community have figured out the coordination of complex care. Unfortunately, the ways by which we pay for health care do not yet reward the coordination of care as much as they reward the direct provision of care and the performance of procedures. We will be open minded and see what happens. In most cases, the responsibility for care coordination falls on the shoulders of patients and their families. I hope we are pleasantly surprised to find that things have begun to change.
So... maybe today, maybe tomorrow we'll be headed home to Concord. Will keep you "posted."
Then there are the new teams that will need to become involved in addition to Sarah's primary care medical home - Critical Care Systems, which is the vendor that will provide all of the equipment needed to maintain Sarah's PICC line and assure that she can receive an IV dose of penicillin every 4 hours around the clock for 8 weeks; the Concord Regional Visiting Nurse Association, which will provide for all of the necessary blood draws for lab work and change the dressing on her PICC line (a sterile procedure); the Cardiac Rehabilitation Program at Concord Hospital to work on regaining strength and mobility; the local pharmacy for Sarah medication prescriptions.
What is about to unfold is known in the health systems research literature as a "transition of care." Sounds simple enough, and it must happen thousands of times a day in this country. However, our health care system is notorious for handling this poorly. Poor transitions to home care constitute one of the leading reasons for avoidable readmissions to the hospital. Good transitions require the ingredient that the Institute of Medicine says is most lacking in US health care - care coordination. We are about to find out if DHMC and the Concord health care community have figured out the coordination of complex care. Unfortunately, the ways by which we pay for health care do not yet reward the coordination of care as much as they reward the direct provision of care and the performance of procedures. We will be open minded and see what happens. In most cases, the responsibility for care coordination falls on the shoulders of patients and their families. I hope we are pleasantly surprised to find that things have begun to change.
So... maybe today, maybe tomorrow we'll be headed home to Concord. Will keep you "posted."
Best of luck. The journey continues but you guys have an amazing dynamic and such strength. For what little comfort it is, we use Critical Care Systems for everything and they are wonderful. so good you'll be getting help. Thanks for the frequent updates, that's not always easy! Hugs and positivity to all.
ReplyDelete-Mal Cyr
OK, I must tell you I was one of those who missed the blog yesterday :)
ReplyDeleteI admit it, I am addicted.
You are so close to your goal of going home together as a family. This is good, in fact this is awesome.
You have our support, our love and our prayers!!! Stay strong, you are all amazing.
Marzelli Deli is ready to do home delivery to the Cooley's!!
Mary
P.S. Love all the new pictures...they bring back lots of "Bradford school days" memories :)
ReplyDeleteThanks, Mary. The great circle of friends of our children and of ours from those Bradford school days remains alive and wonderful.
ReplyDeleteAnd, Mal - thanks so much for vetting the Critical Care Systems people. It is so hard to evaluate quality of vendors during the hours before discharge. Your good opinion means a great deal!