Post Acute Care/ Discharge Care
BridgeCare's Discharge Service offers starting (up to 60 days) of anticoagulation management
and orders in the patient's home.
The goal is to stabilize INRs and educate the patient during this time.
Home Anticoagulation Management
BridgeCare Specialists of Michigan offers anticoagulation therapy management as a crucial long-term treatment for patients at risk of developing blood clots. It can help prevent serious complications such as strokes, heart attacks, and pulmonary embolisms, and improve overall outcomes for patients with these conditions. However, long-term anticoagulation therapy must be carefully managed by a healthcare provider, as it can increase the risk of bleeding complications.
Personalized discussion of risks and benefits of anticoagulation therapy: anticoagulation therapy can provide significant benefits for patients, but it also carries certain risks. A risk and benefit discussion is necessary to determine whether anticoagulation therapy is appropriate for a particular patient, and to ensure that patients are fully informed about the potential benefits and risks of anticoagulation therapy. Discussion on goals of care and risk optimization is important to have with patients and their caregivers for both adherence and reduction of complications.
Prevention of blood clots: Many patients are at risk of developing blood clots after hospitalization, particularly those who have had surgery or a medical condition that limits their mobility. Anticoagulation therapy can help prevent the formation of blood clots and reduce the risk of potentially life-threatening conditions such as deep vein thrombosis (DVT) and pulmonary embolism (PE).
Optimization of anticoagulation therapy: Anticoagulation therapy requires careful management to ensure that the medication is being used appropriately and effectively. Regular follow-up appointments with a healthcare provider can help ensure that the patient is receiving the correct dosage of medication and that any necessary adjustments are made in a timely manner.
Management of side effects and complications: Anticoagulation therapy can increase the risk of bleeding, and patients need to be monitored for any signs of bleeding or other complications. Regular follow-up appointments can help detect and manage any potential side effects or complications of anticoagulation therapy.
Patient education and support: Anticoagulation therapy can be complex and may require lifestyle changes, such as avoiding certain activities or medications. Regular follow-up appointments can provide an opportunity for patient education and support, helping patients better understand their condition and treatment options
Overall, anticoagulation management post-hospitalization is an important part of ensuring that patients receive appropriate and effective care following a hospitalization. By providing regular follow-up appointments and support, healthcare providers can help reduce the risk of complications and improve outcomes for patients on anticoagulation therapy.
DOAC may not be used or may be used with caution. Here are some examples:
Severe kidney disease: DOACs are primarily eliminated by the kidneys, and patients with severe kidney disease may not be able to clear the medication from their body adequately. In such cases, the use of a DOAC may be contraindicated or require dose adjustment.
Pregnancy and breast-feeding: DOACs may not be recommended for pregnant or breastfeeding women due to limited data on their safety in these populations.
Active bleeding: DOACs, like all anticoagulants, increase the risk of bleeding. They should be used with caution in patients who are at increased risk of bleeding, such as those with a recent major bleeding event or who are taking other medications that increase bleeding risk.
Mechanical heart valves: DOACs are generally not recommended for patients with mechanical heart valves, as these patients require a higher level of anticoagulation than is typically achieved with a DOAC.
Certain medical conditions: DOACs may be contraindicated or require dose adjustment in patients with certain medical conditions, such as liver disease, certain types of cancer, or a history of stroke or bleeding.
It's important to note that the decision to use a DOAC should be made on an individual basis by a healthcare provider, taking into account the patient's specific medical history, medication regimen, and overall health status. Regular monitoring of the patient's kidney function, bleeding risk, and other factors is also necessary to ensure the safe and effective use of DOACs.
Improved medication management: Anticoagulation therapy requires careful monitoring and management to ensure that patients are receiving the appropriate dosage and that any necessary adjustments are made in a timely manner. Providing anticoagulation management as a discharge service can help ensure that patients have the support they need to manage their medication effectively.
Reduced risk of complications: Anticoagulation therapy can increase the risk of bleeding, and patients need to be monitored for any signs of bleeding or other complications. Providing anticoagulation management as a discharge service can help detect and manage any potential side effects or complications of anticoagulation therapy, reducing the risk of adverse events.
Patient education and support: Anticoagulation therapy can be complex, and patients may need support to understand their condition and treatment options. Providing anticoagulation management as a discharge service can help ensure that patients receive the education and support they need to manage their condition effectively.
Improved patient outcomes: By providing regular follow-up appointments and support, anticoagulation management as a discharge service can help improve patient outcomes, reducing the risk of hospital readmissions and improving overall quality of care.
A broad range of services is offered to complement all other care and designed to ensure healthcare continuity, avoid preventable poor outcomes, and promote the safe and timely transfer of patients.
BridgeCare can accept referrals from the following locations:
Inpatient acute care hospital
Inpatient psychiatric hospital
Hospital Observation Units
Patients leaving the Emergency Room or Urgent care are not eligible for discharge services through BridgeCare.
BridgeCare coordinates video visits in the comfort of the patients home.
What we do:
Quick Follow-Up Contact
If patients don't hear from us while they're still in inpatient care, they can expect a call within the first day or two after discharge.
Review of Discharge
We go over the patient's inpatient stay and help them make an indivualized plan of recovery.
BridgeCare partners closely with home cares to make sure patients are getting the services they need, as soon as they can.
We offer weekly video or phone follow-up appointments . We check in with a patients' progress and make sure their needs are being met.
Appointments Within 7 Days
All our new patient appointments typically happen within the first seven days of discharge, which helps 'bridge' patients and meet their most pressing needs.
Our providers adjust medications, refill prescriptions, and even oversee IV antibiotics and parenteral nutrition.
For patients with chronic conditions, BridgeCare offers health literacy coaching. Our goal is to make sure patients understand how to best care and advocate for themselves. In doing so we can empower them to seek care at the appropriate places.
When it's time for patients to 'graduate' from our services, we ensure they have enough medications and resources to take the next step in their care.