Leslie Smith

Inpatient to outpatient, WellMed team ensures seamless transition of care

82-year-old WellMed patient, Leslie Smith, had been experiencing debilitating knee pain for more than 20 years. The pain had become so severe over the last year that she knew she needed to do something about it.

Brady Harrison, physician assistant at WellMed at Schertz in Schertz, Texas near San Antonio examined her and knew she needed to see a specialist. He was right in his initial assumption that she would need a knee replacement.

After her surgery, Leslie recovered quickly. She was released from the hospital the next day and began physical therapy at home for two weeks. She then transitioned to in-office physical therapy three times a week.

Leslie was so pleased with the care she received from her health care team. She was especially impressed with Dr. Steven Solis, the WellMed hospitalist who cared for her during her stay in the hospital. Dr. Solis went the extra mile to make sure Leslie had everything she needed, and he even helped her find a coupon for a medication she could not afford.

“I just adored my hospitalist,” Leslie shared. “Dr. Solis went above and beyond to make sure I was comfortable and had everything I needed. I wasn’t expecting that kind of care from a doctor I had never met before.”

Dr. Solis, Northeast hospitalist lead physician for WellMed, emphasized the importance of a smooth transition of care for patients like Leslie.

“Our main goal is to have a seamless transition between the outpatient and inpatient setting,” Dr. Solis explained. “When patients are discharged from the hospital, it’s critical we have a plan for how they will continue to receive the right care in the outpatient setting. This includes making sure they have the right medications, they are following up with their primary care provider and they are aware of any potential complications.” He noted that providers who work together can ensure patients have uninterrupted care and don’t end up back in the hospital.

Prior to Leslie’s surgery, her care team at WellMed at Schertz already had her follow-up appointment scheduled. Gregorio Jimenez, Jr., physician assistant, saw Leslie at her follow-up visit.

Gregorio emphasized the importance of continuity of care for patients like Leslie. He said, “We focus on seeing patients at least three times within 30 days after leaving the hospital. We hope to see the patient face-to-face or through virtual visits if needed, in order to achieve our “3-in-30” goal.”

He shared, “Our goal with follow-up visits is to avoid readmission and ensure all referrals and medications are up to date.”

Leslie is now four weeks out from her surgery, and she is doing great. “My transition from hospital to home care was smooth as silk,” she said.

Leslie is continuing her regular physical therapy. She has recovered to the point where she is walking without any pain and is able to perform most of her normal activities. She is thankful for the care and support she has received from the entire WellMed team, including her hospitalist and the staff at WellMed Schertz. They have been instrumental in helping her recover.

“I am so pleased with the quality care WellMed provides,” Leslie said. “I will continue to recommend WellMed to everyone I know.”