Post Hospital Discharge and Follow Ups
4 steps to maintaining communication after discharge
It’s no secret that engaging patients in their care is essential to supporting care quality, increasing patient satisfaction and, ultimately, achieving positive patient outcomes. However, when the patient leaves the hospital, it can be challenging to sustain patient engagement, especially when it comes to maintaining communication and overseeing care continuity.
Despite the changing healthcare environment, hospitals and post-acute providers remain relatively disconnected from one another, making patients and their families primarily responsible for following care plans developed in the acute setting. As such, engaging patients and their support system in post-acute care is paramount to maintaining the patient’s recovery or chronic disease management and limiting the potential for avoidable readmissions.
Though patient and family engagement can be tough once a patient is “out of sight,” hospitals can pursue the following four steps to facilitate communication, continue oversight and ensure patients follow their care plans.
- Step One: Help the Patient and Family Understand the Diagnosis.
- Step Two: Ensure the Patient and Family Are Committed to the Care Plan.
- Step Three: Keep the Patient and Family Actively Involved in Care Transitions.
- Step Four: Leverage Technology to Continue Patient Oversight.
Checklist for Post-Hospital Follow-Up Visits
Prior to the Visit
- Review discharge Summary.
- Clarify outstanding questions with sending physician.
- Reminder call to patient or family caregiver to:
- Stress importance of the visit and address any barriers.
- Remind to bring medication lists and all prescribed and over-the-counter preparations.
- Provide instructions for seeking emergency and non-emergency after-hours care.
- Coordinate care with home health care nurses and case managers if appropriate.
During the Visit
- Ask the patient to explain:
- His/her goals for visit.
- What factors contributed to hospital admission or ED visit.
- What medications he/she is taking and on what schedule.
- Perform medication reconciliation with attention to the pre-hospital regimen.
- Determine the need to:
- Adjust medications or dosage;
- Follow up on test results;
- Do monitoring or testing;
- Discuss advance directives;
- Discuss specific future treatments (POLST).
- Instruct patient in self-management; have patient repeat back.
- Explain warning signs and how to respond; have patient repeat back.
- Provide instructions for seeking emergency and no-emergency after-hours care.
At the Conclusion of the Visit
- Print reconciled, dated medication list and provide a copy to the patient, family caregiver, home health care nurse, and case manager (if appropriate).
- Communicate revisions to the care plan to the family care givers, health care nurses, and case managers (if appropriate). Consider skilled home health care or other supportive services.
- Ensure that the next appointment is made.