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What are Transitions of Care and How Do They Improve Your Health Care Experience?
The Centers of Medicare and Medicaid Services (CMS) define transitions of care as the movement of a patient from one setting of care to another. Listen as Dr. Mary Lomberk, a transitions of care clinical pharmacist with BayCare, discusses what transitions of care means, useful questions to ask your doctor before you leave the hospital, who helps you with these changes and more.
Featured Speaker:
In her current role, Dr. Lomberk provides continuity of care for hospitalized patients by working with an interdisciplinary team to resolve medication errors, promote patient education and reduce hospital readmissions. Dr. Lomberk was recognized at the 2019 BayCare’s Quality Sharing Day for a remarkable patient story and outcome and serves as a Pharmacist Advisory Committee member for the National Transitions of Care Coalition. She has a passion for mentoring and precepts students and residents as well and serves as a UF mentor and research advisor.
Mary Lomberk, PharmD, BCACP
Dr. Mary Lomberk is a Transitions of Care clinical pharmacist with BayCare in Tampa, Florida. Dr. Lomberk is a graduate of Wingate University School of Pharmacy and completed her PGY1 residency training at Novant Health in Winston Salem, NC focusing in ambulatory care and population health. She is a board-certified ambulatory care pharmacist and has helped develop and expand the transitions of care program and ambulatory care pharmacy presence within BayCare since joining the health system in 2016.In her current role, Dr. Lomberk provides continuity of care for hospitalized patients by working with an interdisciplinary team to resolve medication errors, promote patient education and reduce hospital readmissions. Dr. Lomberk was recognized at the 2019 BayCare’s Quality Sharing Day for a remarkable patient story and outcome and serves as a Pharmacist Advisory Committee member for the National Transitions of Care Coalition. She has a passion for mentoring and precepts students and residents as well and serves as a UF mentor and research advisor.
Transcription:
What are Transitions of Care and How Do They Improve Your Health Care Experience?
Intro: This is BayCare Health Chat, another podcast from BayCare Health System.
Maggie McKay (Host): Welcome to BayCare HealthChat. I'm Maggie McKay. The good news, your hospital stay is about to come to an end and it's time to go home. But with that also comes a lot of questions, uncertainty and not knowing what to expect. In this episode, we're going to talk about transitions of care, what that means, useful questions to ask your doctor before you leave the hospital, who helps you figure it all out and more? My guest today is Dr. Mary Lomberk, a transitions of care clinical pharmacist with BayCare in Tampa, Florida. Welcome Dr. Lomberk thank you so much for making the time to be with us and help us understand.
Dr. Mary Lomberk: Yes. Thank you for having.
Maggie McKay (Host): So let's dig right in. What is transitions of care?
Dr. Mary Lomberk: That's a good question. Well CMS or the Centers for Medicare and Medicaid Services, defines this idea of transitions of care really is any movement of a patient from one care setting to another. So that could be from a hospital to home, that could be hospital to a rehabilitation center or rehab center, that can even be at a point when patients and family are considering stepping up to hospice. That's also another point of transition. During these times of transition, we know that they're actually prone to errors because there's just a lack of communication and follow-up that can happen.
And we know that during these transitions, correct communication and understanding are really key factors for the success of a patient's health care journey. CMS and many other hospitals and healthcare systems are really focusing their efforts, to ensure smooth transitions from one care setting to another, like at your hospital discharge.
Maggie McKay (Host): You're getting discharged or transitioning to another location. Now what it's got to be overwhelming. What about the discharge paperwork to start with?
Dr. Mary Lomberk: We understand that most patients are excited to hear that they're being discharged from the hospital. and we understand that the discharge process can really be a whirlwind of events, and a lot of information for patients and families to process, and we get that. It's hard to pay attention to those small details once you've heard the words you're going home today. So that being said if you do miss some of those details at discharge, your discharge paperwork is a great resource for you and your family.
Maggie McKay (Host): And what does it entail? What should it include?
Dr. Mary Lomberk: Typically there are six to seven components of your discharge paperwork that's worth reviewing. There'll be a reason for your admission. This may be new diagnosis for you or maybe something you were already aware of. If there are questions about these diagnoses that are listed, your best resource is really to reach out to your family care or primary care physician. It also lists on your discharge paperwork who you need to follow up with. That's an important piece, to make sure you review that list, it may include specialists such as a cardiologist or a surgeon, depending on what you're in the hospital for.
And typically, this list will include PCP, your primary care physician or provider. And that's just because most family care doctors, or PCPs want to be able to see you, to provide a transitional care up visit after your hospital stay. A really important part is to review your medication list on your discharge paperwork, this will reflect your medication plan, after you leave the hospital. And we can talk a little bit about the specifics of reviewing your medication list a little later, if you'd like, but in general, it's an important one to understand.
A lot of times your discharge paperwork will include what to expect from your diet and exercise or activity level. Most of them may say that you can resume your normal diet or normal activity level, but maybe if you'd just gone through a surgery, you may have a little bit more specifics on what you should expect from your diet or the limits to your activity level that would be important to review. Some people when they leave the hospital may expect, home health care services after discharge. And this can be an extra resource for you at home.
After your hospital stay, home health care services can include anything from nursing assistance in the home, physical therapy, occupational therapy, depending on your individual situation. And then lastly, most discharge paperwork will include some educational information for you about your recent diagnoses, or treatments and procedures that you may have just went through. There may even be some information on the new medications and what to expect from them as well in your hospital discharge.
Maggie McKay (Host): I remember the few times I've been in the hospital and was about to leave. Wow. Like you said a whirlwind, there's so much activity. You're packing up. You're reading this list. You're talking to all the people that come in and out, I have to say, I just gave it to my husband. And I say, can you review this? Because he's a stickler for details. Do you recommend, of course having the patient look it over, but also having like an advocate to help you?
Dr. Mary Lomberk: Yeah, absolutely. That's, always a great idea and plan. because again, we understand that if you were in the hospital, maybe you weren't at your best. Maybe you were sick getting through something, so it is a lot to process. You're just trying to work on your body, getting healthy again, right, for the most part. So, having someone that could look over the fine details, make sure everything adds up and connects well, is a great thing to have them review as well.
Maggie McKay (Host): Dr. Lomberk, what is your role in transitions of care? Do you talk to the patient before they leave about their medication? Or how does that work?
Dr. Mary Lomberk: BayCare really has been an innovator and working in the transition of care space and providing resources to ensure, safe transitions. As BayCare has actually employed teams of pharmacists like myself, there are also nurses, that are RNs or LPNs, as well as social workers, even nurse practitioners, that work on this, interdisciplinary team so that we can provide smooth transitions from hospital to home or even hospitals to rehab centers and other points of transition. In my role, I work with a team of pharmacists. We actually started off in 2015 with just two pharmacists and now have expanded to over 44 pharmacists that support transitions of care.
And this program, I'm really proud of, it's been recognized locally for its quality patient care within BayCare, but also on a state and national level by winning best practice awards in this area of transitions of care. So, our team of pharmacists, we cover Medicare patients that are 65 years and older that have been admitted to one of our BayCare adult hospitals. We cover over 40,000 patients per year typically, and we help with that transitions of care in two ways. One, we follow patients from day one of their admission.
You may not see us at the bedside, but we are working in the background. And what we're doing is helping the doctors and team get ready for discharge to help plan the patient's discharge medication list. And from there, the doctors and providers review that list to make sure that there's no concerns. We help to ensure patient safety with your medications to make sure your medication list doesn't have drug interactions on them. There's no duplicate medications and really to kind of help optimize your medication list for when you leave.
And then secondly, where you may hear from us, in the community is that we provide a post discharge phone call after a patient gets home. and that's the patients that either go home or home with home health. We provide medication review, with you or a family member. We also provide, essential education and really answering any questions that you might have after discharge.
Maggie McKay (Host): I have to say I had no idea all this went on behind the scenes, you know, as a patient. What common questions do you ask your doctor at your follow-up appointment? You've been home a while and now there are probably a whole new list of questions. What should you be asking at the follow up?
Dr. Mary Lomberk: Yeah, there are some questions that you should maybe consider asking, and obviously as a pharmacist, some of the things I focus on is your medication list. Something you'd want to consider would be, asking your doctor, can we review my medication list and bringing that discharge paperwork with you to your follow up appointments can be very helpful and beneficial while you're in the visit with your doctors. Some of your other questions you might want to consider is do you need refills for these medications?
A lot of times when you leave the hospital, new medications may not have refills, so asking your doctor questions about, how long will these medications be continued? And do I need refills? Are good questions to ask and then kind of lastly, if you're still not feeling well after a hospital discharge maybe asking those questions of what should I expect moving forward? Or if you've recently got a new diagnosis, what are next steps that I should expect after this new diagnosis? Are important questions to ask your, family doctor or at those specialist follow-up appointments.
Maggie McKay (Host): I think it's invaluable information to remember, to hang on to that paperwork you get when you're discharged and take it to the follow-up appointment because a lot of people get home and they like to just clear out the paperwork. But if you have your discharge paperwork with you, that's helpful for the doctor, right?
Dr. Mary Lomberk: Yeah, absolutely. There's a lot of times that I have, asked patients if they could go pull it out of their trash bins because we know that sometimes paperwork can be daunting to look through all those small details, especially again, if you weren't feeling well, but really reviewing paperwork just to make sure. And then yes, again, it does help your providers at those follow-up appointments as well.
Maggie McKay (Host): I know we did touch on this, but can you tell us just a little bit more about transitions of care within BayCare? What makes BayCare extra special?
Dr. Mary Lomberk: BayCare really has been an innovator and working in this transition of care space and providing resources to ensure, safe transitions. So BayCare has actually employed teams across the health care system of nurses, social workers, nurse practitioners, and pharmacists, like myself, and we all work collaboratively as a team, to help provide smooth transitions as patients discharge from our hospital.
Maggie McKay (Host): That's a lot of different teams. That's impressive. And so the transitions of care pharmacists, what is their service within BayCare? I mean, you talked a little bit about what you do, but in general.
Dr. Mary Lomberk: In general, we will provide, basically kind of two services, one we're, actually, while the patients being, inpatient, we will review their medications while they're still here in the hospital and help the doctors plan the discharge medication list so that it's ready to go. Hopefully free of errors, any kind of drug interaction, duplicate medications and so forth. All of this is to help ensure patient safety and optimize your medication lists going home. And then secondly, we provide post-discharge follow-up calls with patients and or their family members, that go home or go home with home health care services.
During those calls, we review your medications making sure that there weren’t any questions or calls for concern, make sure you've been able to tolerate your medications if there was anything that was new, as well as making sure that you recognized on that discharge paperwork there may have been medications to stop taking that is sometimes just as important as understanding to take your new medication. And all of this is done to provide education to the patient and their family and answer any questions they might have after discharge.
Our whole goal is really to ensure patient safety through these times of transitions, and in doing so, we also hope to reduce your risk of being readmitted to a hospital because ultimately our goal is to keep our patients home and healthy as possible and out of our hospitals if we can.
Maggie McKay (Host): Is there anything else you'd like to add that we didn't cover that you'd like to share?
Dr. Mary Lomberk: I'm glad to have been able to enlighten anyone about this discharge process. Like we had said before, it's a whirlwind of events that happen and you're just so excited to be home and we know that you want to be able to rest and recover. And again, within BayCare, our goal is to keep you home and healthy and out of our hospitals, if we can. We want to optimize your health care journey through these transitions.
Maggie McKay (Host): That's wonderful. Thank goodness for the transitions of care teams. Dr. Lomberk this has been so educational and I learned a lot today. I'm sure you helped a lot of other people too, by sharing your knowledge. We appreciate you being here.
Dr. Mary Lomberk: Thank you so much for having me.
Maggie McKay (Host): And that wraps up this episode of BayCare HealthChat, head on over to our website at BayCare.org for more information, and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other BayCare podcasts. For more health tips and updates, follow us on your social channels. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. I'm Maggie McKay. Thanks for joining us and be well.
What are Transitions of Care and How Do They Improve Your Health Care Experience?
Intro: This is BayCare Health Chat, another podcast from BayCare Health System.
Maggie McKay (Host): Welcome to BayCare HealthChat. I'm Maggie McKay. The good news, your hospital stay is about to come to an end and it's time to go home. But with that also comes a lot of questions, uncertainty and not knowing what to expect. In this episode, we're going to talk about transitions of care, what that means, useful questions to ask your doctor before you leave the hospital, who helps you figure it all out and more? My guest today is Dr. Mary Lomberk, a transitions of care clinical pharmacist with BayCare in Tampa, Florida. Welcome Dr. Lomberk thank you so much for making the time to be with us and help us understand.
Dr. Mary Lomberk: Yes. Thank you for having.
Maggie McKay (Host): So let's dig right in. What is transitions of care?
Dr. Mary Lomberk: That's a good question. Well CMS or the Centers for Medicare and Medicaid Services, defines this idea of transitions of care really is any movement of a patient from one care setting to another. So that could be from a hospital to home, that could be hospital to a rehabilitation center or rehab center, that can even be at a point when patients and family are considering stepping up to hospice. That's also another point of transition. During these times of transition, we know that they're actually prone to errors because there's just a lack of communication and follow-up that can happen.
And we know that during these transitions, correct communication and understanding are really key factors for the success of a patient's health care journey. CMS and many other hospitals and healthcare systems are really focusing their efforts, to ensure smooth transitions from one care setting to another, like at your hospital discharge.
Maggie McKay (Host): You're getting discharged or transitioning to another location. Now what it's got to be overwhelming. What about the discharge paperwork to start with?
Dr. Mary Lomberk: We understand that most patients are excited to hear that they're being discharged from the hospital. and we understand that the discharge process can really be a whirlwind of events, and a lot of information for patients and families to process, and we get that. It's hard to pay attention to those small details once you've heard the words you're going home today. So that being said if you do miss some of those details at discharge, your discharge paperwork is a great resource for you and your family.
Maggie McKay (Host): And what does it entail? What should it include?
Dr. Mary Lomberk: Typically there are six to seven components of your discharge paperwork that's worth reviewing. There'll be a reason for your admission. This may be new diagnosis for you or maybe something you were already aware of. If there are questions about these diagnoses that are listed, your best resource is really to reach out to your family care or primary care physician. It also lists on your discharge paperwork who you need to follow up with. That's an important piece, to make sure you review that list, it may include specialists such as a cardiologist or a surgeon, depending on what you're in the hospital for.
And typically, this list will include PCP, your primary care physician or provider. And that's just because most family care doctors, or PCPs want to be able to see you, to provide a transitional care up visit after your hospital stay. A really important part is to review your medication list on your discharge paperwork, this will reflect your medication plan, after you leave the hospital. And we can talk a little bit about the specifics of reviewing your medication list a little later, if you'd like, but in general, it's an important one to understand.
A lot of times your discharge paperwork will include what to expect from your diet and exercise or activity level. Most of them may say that you can resume your normal diet or normal activity level, but maybe if you'd just gone through a surgery, you may have a little bit more specifics on what you should expect from your diet or the limits to your activity level that would be important to review. Some people when they leave the hospital may expect, home health care services after discharge. And this can be an extra resource for you at home.
After your hospital stay, home health care services can include anything from nursing assistance in the home, physical therapy, occupational therapy, depending on your individual situation. And then lastly, most discharge paperwork will include some educational information for you about your recent diagnoses, or treatments and procedures that you may have just went through. There may even be some information on the new medications and what to expect from them as well in your hospital discharge.
Maggie McKay (Host): I remember the few times I've been in the hospital and was about to leave. Wow. Like you said a whirlwind, there's so much activity. You're packing up. You're reading this list. You're talking to all the people that come in and out, I have to say, I just gave it to my husband. And I say, can you review this? Because he's a stickler for details. Do you recommend, of course having the patient look it over, but also having like an advocate to help you?
Dr. Mary Lomberk: Yeah, absolutely. That's, always a great idea and plan. because again, we understand that if you were in the hospital, maybe you weren't at your best. Maybe you were sick getting through something, so it is a lot to process. You're just trying to work on your body, getting healthy again, right, for the most part. So, having someone that could look over the fine details, make sure everything adds up and connects well, is a great thing to have them review as well.
Maggie McKay (Host): Dr. Lomberk, what is your role in transitions of care? Do you talk to the patient before they leave about their medication? Or how does that work?
Dr. Mary Lomberk: BayCare really has been an innovator and working in the transition of care space and providing resources to ensure, safe transitions. As BayCare has actually employed teams of pharmacists like myself, there are also nurses, that are RNs or LPNs, as well as social workers, even nurse practitioners, that work on this, interdisciplinary team so that we can provide smooth transitions from hospital to home or even hospitals to rehab centers and other points of transition. In my role, I work with a team of pharmacists. We actually started off in 2015 with just two pharmacists and now have expanded to over 44 pharmacists that support transitions of care.
And this program, I'm really proud of, it's been recognized locally for its quality patient care within BayCare, but also on a state and national level by winning best practice awards in this area of transitions of care. So, our team of pharmacists, we cover Medicare patients that are 65 years and older that have been admitted to one of our BayCare adult hospitals. We cover over 40,000 patients per year typically, and we help with that transitions of care in two ways. One, we follow patients from day one of their admission.
You may not see us at the bedside, but we are working in the background. And what we're doing is helping the doctors and team get ready for discharge to help plan the patient's discharge medication list. And from there, the doctors and providers review that list to make sure that there's no concerns. We help to ensure patient safety with your medications to make sure your medication list doesn't have drug interactions on them. There's no duplicate medications and really to kind of help optimize your medication list for when you leave.
And then secondly, where you may hear from us, in the community is that we provide a post discharge phone call after a patient gets home. and that's the patients that either go home or home with home health. We provide medication review, with you or a family member. We also provide, essential education and really answering any questions that you might have after discharge.
Maggie McKay (Host): I have to say I had no idea all this went on behind the scenes, you know, as a patient. What common questions do you ask your doctor at your follow-up appointment? You've been home a while and now there are probably a whole new list of questions. What should you be asking at the follow up?
Dr. Mary Lomberk: Yeah, there are some questions that you should maybe consider asking, and obviously as a pharmacist, some of the things I focus on is your medication list. Something you'd want to consider would be, asking your doctor, can we review my medication list and bringing that discharge paperwork with you to your follow up appointments can be very helpful and beneficial while you're in the visit with your doctors. Some of your other questions you might want to consider is do you need refills for these medications?
A lot of times when you leave the hospital, new medications may not have refills, so asking your doctor questions about, how long will these medications be continued? And do I need refills? Are good questions to ask and then kind of lastly, if you're still not feeling well after a hospital discharge maybe asking those questions of what should I expect moving forward? Or if you've recently got a new diagnosis, what are next steps that I should expect after this new diagnosis? Are important questions to ask your, family doctor or at those specialist follow-up appointments.
Maggie McKay (Host): I think it's invaluable information to remember, to hang on to that paperwork you get when you're discharged and take it to the follow-up appointment because a lot of people get home and they like to just clear out the paperwork. But if you have your discharge paperwork with you, that's helpful for the doctor, right?
Dr. Mary Lomberk: Yeah, absolutely. There's a lot of times that I have, asked patients if they could go pull it out of their trash bins because we know that sometimes paperwork can be daunting to look through all those small details, especially again, if you weren't feeling well, but really reviewing paperwork just to make sure. And then yes, again, it does help your providers at those follow-up appointments as well.
Maggie McKay (Host): I know we did touch on this, but can you tell us just a little bit more about transitions of care within BayCare? What makes BayCare extra special?
Dr. Mary Lomberk: BayCare really has been an innovator and working in this transition of care space and providing resources to ensure, safe transitions. So BayCare has actually employed teams across the health care system of nurses, social workers, nurse practitioners, and pharmacists, like myself, and we all work collaboratively as a team, to help provide smooth transitions as patients discharge from our hospital.
Maggie McKay (Host): That's a lot of different teams. That's impressive. And so the transitions of care pharmacists, what is their service within BayCare? I mean, you talked a little bit about what you do, but in general.
Dr. Mary Lomberk: In general, we will provide, basically kind of two services, one we're, actually, while the patients being, inpatient, we will review their medications while they're still here in the hospital and help the doctors plan the discharge medication list so that it's ready to go. Hopefully free of errors, any kind of drug interaction, duplicate medications and so forth. All of this is to help ensure patient safety and optimize your medication lists going home. And then secondly, we provide post-discharge follow-up calls with patients and or their family members, that go home or go home with home health care services.
During those calls, we review your medications making sure that there weren’t any questions or calls for concern, make sure you've been able to tolerate your medications if there was anything that was new, as well as making sure that you recognized on that discharge paperwork there may have been medications to stop taking that is sometimes just as important as understanding to take your new medication. And all of this is done to provide education to the patient and their family and answer any questions they might have after discharge.
Our whole goal is really to ensure patient safety through these times of transitions, and in doing so, we also hope to reduce your risk of being readmitted to a hospital because ultimately our goal is to keep our patients home and healthy as possible and out of our hospitals if we can.
Maggie McKay (Host): Is there anything else you'd like to add that we didn't cover that you'd like to share?
Dr. Mary Lomberk: I'm glad to have been able to enlighten anyone about this discharge process. Like we had said before, it's a whirlwind of events that happen and you're just so excited to be home and we know that you want to be able to rest and recover. And again, within BayCare, our goal is to keep you home and healthy and out of our hospitals, if we can. We want to optimize your health care journey through these transitions.
Maggie McKay (Host): That's wonderful. Thank goodness for the transitions of care teams. Dr. Lomberk this has been so educational and I learned a lot today. I'm sure you helped a lot of other people too, by sharing your knowledge. We appreciate you being here.
Dr. Mary Lomberk: Thank you so much for having me.
Maggie McKay (Host): And that wraps up this episode of BayCare HealthChat, head on over to our website at BayCare.org for more information, and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other BayCare podcasts. For more health tips and updates, follow us on your social channels. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. I'm Maggie McKay. Thanks for joining us and be well.