4 pillars of patient care after discharge


As hospitals struggle to reduce readmissions and improve quality, they are increasingly looking beyond the organization’s four walls to manage patients after discharge. By extending care beyond the hospital stay, hospitals can improve patient health and prevent readmissions. Sean Hughes, Vice President of Hospital Transition Services Provider Vree Healthshares four pillars of post-discharge patient care that hospitals should address in discharge planning.

1. Transfers. The transition of patients between healthcare providers and from hospital to home is one of the most vulnerable areas for patient safety. Hospitals should ensure that hospital staff and physicians communicate clearly so that all members of the healthcare team are aware of the patient’s situation and needs. In particular, timely communication of the hospital discharge plan to the patient’s treating physician is critical at the time of discharge.

2. Tracking. Follow-up of patients after discharge is crucial to prevent readmissions. Hospitals should check in with patients after discharge to ensure they are following discharge instructions, such as scheduling an appointment with a primary care physician, and to determine if they have experienced a relapse of symptoms .

One of the ways hospitals can keep track of patients is to provide a bridging liaison, Hughes says. At Vree Health, the Transition Liaison Officer starts assisting patients before they are discharged from the hospital and is responsible for contacting the patient daily for the first 30 days after discharge to check on the patient’s health status and provide the necessary services. For example, the liaison worker might help patients arrange transportation to an appointment with a primary care provider or specialist.

In addition to preventing readmissions, engaging patients after discharge helps create a positive image of the hospital in the community. “Maintaining patient engagement and building relationships with patients across the continuum of care can improve hospital branding,” Hughes said.

3. Coordination of care.
Coordinating care when patients leave the hospital can help prevent readmissions and improve patient health. Hospitals should communicate with patients’ primary care physicians, caregivers, and other providers when planning care for the patient after discharge.

Caregivers in particular play an important role in the health of patients after discharge, as they can often be responsible for driving the patient to appointments and assisting with post-discharge instructions. Hughes suggests that hospitals encourage patients to invite their caregiver to the post-discharge planning session so that the caregiver is informed. “By bringing [caregivers] in that care, you provide the nurturing environment that patients need,” he says.

4. Medicines. Non-compliance with medication instructions is a major factor in readmission. Hospitals can prevent medication-related readmissions by discussing patients’ medications prior to discharge and following up with the patient to ensure they have filled their prescriptions and understand how to take their medications.

More articles on hospital readmissions:

Process of care measures not linked to reduced readmissions, study finds
Hospitals and call centers play a crucial role in reducing readmissions
Stratify and manage your emergency patient populations: the importance of streamlined follow-up communication

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