EXPERT CARE COORDINATION | STAYING OUT OF THE HOSPITAL
Preventing and Recovering from Hospitalizations
Preventing hospitalizations is a top priority at ICS. Hospital stays, while sometimes necessary, have inherent risks and can be especially dangerous and frightening for someone with a physical disability. Often these individuals come home from a hospital or nursing home stay with more complications and less functional ability than when they went in, triggering a second hospitalization that becomes the start of a downward spiral.
ICS helps our members prevent unnecessary hospitalizations by providing disability-expert care management and ensuring they have access to disability-competent healthcare providers for primary care and preventative services.
ICS members benefit from our longstanding partnerships with disability-competent medical providers who offer accessible mammography, gynecological care, radiology and primary care. Trained by ICS to work with individuals with disabilities, these providers are able to identify and treat potentially dangerous medical conditions before they grow serious enough to require hospitalization.
ICS care coordination includes teaching members to prevent conditions like pressure wounds and urinary tract infections that commonly land people with disabilities in the hospital. It also includes access to a specialized wound care team, and comprehensive wheelchair evaluations, fittings, maintenance and repairs.
The ICS Transitions Team
When an ICS member is hospitalized, our transition team facilitates a safe return home, working with the member, hospital staff and the member’s caregivers to address barriers to care that the member may need help with during their hospital stay. For example, when someone with a disability is hospitalized and loses the support of their homecare aide, they may be unable to use a typical call bell and require an adaptive piece of equipment in order to call the hospital staff for help.
Upon discharge from the hospital or nursing home, an ICS community health worker makes sure that the member, their aides, and family caregivers understand the member’s condition, medication management and other required follow-up care, and how to identify red flags. They can assist in scheduling follow-up medical appointments and arranging transportation, remind the member about the appointment and, if needed, accompany them. The worker also follows up after the appointment to make sure that the member understands the outcome of the appointment and any medical instructions they received.
These are all important steps in ensuring that our members are able to fully recover after a hospital stay, rather than have their health deteriorate, putting them at risk for another hospital admission. We also know that hospitalizations are very scary to our members. Our goal is to support them and make sure that they receive the services they need to be as healthy as possible, both during and following a hospital stay.