Released but not forgotten: Improving the patient discharge process

It used to be that hospitals behaved like restaurants. Once a patron eats a meal and pays their bill, they walk out the door and the restaurant’s responsibility to provide a great product and service ends. In today’s regulatory environment, however, patient care doesn’t end when a patient checks out of the hospital.

The discharge process represents the front line of attack in the patient rebounding battle. The hospital discharge process is at its best when it takes into account the specific short- and long-term needs of its patients. Being discharged can be stressful and scary foMiles Snowden, MD, MPH, CEBS Chief Medical Officer, OptumHealthr patients, especially those with high-risk conditions that require deeper care well beyond the hospital doors. They may be thinking, “What do I do now?” or “What happens if something goes wrong?”

For hospitals, comprehensive planning processes that incorporate various strategies using best clinical practices and agreed upon by partners can be the difference between a successful patient outcome and a preventable readmission or rebound to the ER.

A solid discharge plan includes three key elements:

  1. Discharge planning upon admission – For patients with high-risk chronic conditions or high-acuity, don’t wait until the last few hours of their stay to plan for the patient’s discharge. Patient expectations can more easily be set, outpatient resources are simpler to secure, and communication channels can be built that can make a longer length of stay much less likely.
  2. Primary care appointment setting Hill Physicians Medical Group of San Ramon, Calif., works with hospital case managers to assess clinical risks for patients nearing discharge to determine how quickly follow-up appointments with primary care physicians are needed. Patients get reminder cards and an auto-generated reminder letter is sent to the patient’s home, in addition to a third reminder from the transition-of-care “Welcome Home” nurse. Hill increased post-discharge primary care follow-up visits compliance from 35 percent to 75 percent through its program.
  3. Teach-back process – One of the best ways to reduce readmissions is to help patients understand their own follow-up needs. This “teach-back” process first educates the patient or his or her caregiver about post-discharge care. Then, the patient is asked to explain in his/her own words what was taught. A few hours later, the patient is asked to “teach-back” again. Re-education is done until the provider is confident the patient understands what needs to be done.

Steward Health Care System in Boston has social workers collaborate with nurses in the discharge process. That way, a patient’s clinical needs are met upon discharge by the nurse while the social worker focuses on assessment and coordination of care once the patient returns home.

Post-discharge follow-ups should happen within two-to-five days, according to the Institute for Healthcare Improvement. To ensure this happens, some systems are reimbursing physicians a higher visit fee when they see patients post discharge within a pre-determined timeframe. Project BOOST (Better Outcomes by Optimizing Safe Transitions) recommends a follow-up phone call within 72 hours to assess patient condition and adherence to discharge instructions.

Improved discharge processes can make a big difference. Optum recently completed a pilot readmission reduction project for a selected population within a 14-hospital system in the southwest United States. Nurses met with and assessed patients, determined what medications they would be taking, and studied living conditions and what care they would receive in the home. A follow-up call was conducted post discharge to ensure prescriptions were filled and in-home treatments were delivered. The program resulted in a 30% reduction in readmissions.

Once a patient is discharged, care transition programs must take over. In our next post, we’ll look at how care transitions can be handled successfully for both patients and their providers.

To read more about discharge planning improvement, download the white paper: “Preventing Patient Rebound: Value-based Care Organizations Should Focus on More Than Just Readmissions.”

Miles Snowden, MD, Chief Medical Officer, Optum

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