4 Pillars of Post-Discharge Patient Care
1. Hand-offs. Patients' transition between healthcare providers and from hospital to home is one of the most vulnerable areas for patient safety. Hospitals need to ensure hospital staff and physicians communicate clearly so everyone on the care team is aware of the patient's situation and needs. In particular, timely communication of the discharge plan from the hospital to the patient's primary physician is critical at the time of discharge.
2. Follow-up. Following up with patients post-discharge is crucial in preventing readmissions. Hospitals should check in with patients after discharge to ensure they follow discharge instructions, such as scheduling an appointment with a primary care physician, and to determine if they have experienced any relapse of symptoms.
One way hospitals can follow-up with patients is by providing a transition liaison, Mr. Hughes says. At Vree Health, the transition liaison begins assisting patients before they leave the hospital and is responsible for contacting the patient daily for the first 30 days post-discharge to check the patient's health status and provide any needed services. For example, the liaison could help patients arrange transportation to an appointment with a primary care provider or specialist.
In addition to preventing readmissions, engaging patients post-discharge builds a positive image of the hospital in the community. "Maintaining patient engagement and building the patient relationship throughout the continuum of care can improve the hospital brand image," Mr. Hughes says.
3. Care coordination. Coordinating care when patients leave the hospital can help prevent readmissions and improve patients' health. Hospitals should communicate with patients' primary care physicians, caregivers and other providers in planning care for the patient post-discharge.
Caregivers in particular play an important role in patients' health after discharge, as they may often be responsible for driving the patient to appointments and helping them follow post-discharge instructions. Mr. Hughes suggests hospitals encourage patients to invite their family caregiver in during the post-discharge planning session so the caregiver is informed. "By bringing [caregivers] into that care, you provide the nurturing environment patients need," he says.
4. Medication. Noncompliance with medication instructions is a major driver of readmissions. Hospitals can prevent medication-related readmissions by discussing patients' medication before discharge and following up with the patient to ensure they filled their prescriptions and understand how to take their medication.
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