By: Dra. Nilsa González DNP FNP-C APRN, AVP Operaciones inHealth Management, LLC

The return of the patient and caregiver to the home environment is a global priority, however, few jurisdictions have intervened with the patient and their caregiver to understand what elements affect the hospital-to-home transition experience. The MSO of Puerto Rico has a team of nursing professionals who use as a basis the postulates of “Coaching” of Dr. Eric Colman to support the post-discharge patient of the Unidad Dorada. The Clinical Liaison (CL) of the MMM Te Cuida Program provides the patient and caregiver with the opportunity to express themselves regarding needs or barriers to discharge to close care gaps. This intervention helps identify barriers or opportunities we have as health care providers to improve the experience which in turn prevents readmission.

The CL assists the physician in estimating real needs based on the condition of the insured at discharge. Kiran, et al (2020) identified six elements that affect the patient’s experience during their transition from hospital to home: home care, the discharge planning process, follow-up appointments with the primary care physician, post-discharge medications, caregiver education level, and team sensitivity and care in the hospital. The CL can work with the doctor to make the patient experience healthy and effective.

To refer cases to the MMMTC Program use the following link:

References: Kiran, T. et al (2020). Patient and Caregiver Experience in the transition from hospital to home-brainstorming results from group concept mapping: a patient -oriented study. CMAJ Open 2020.DOI:10.9778/cmajo.20190009