Today’s hospitals have more than a casual interest in ensuring that inpatient care is complemented by an effective post-discharge care management program, especially as it pertains to the health of our nation’s elderly.
That’s because just such a program can stem the flow of readmissions, decrease excess healthcare use, minimize the need for nursing facility placement, and substantially reduce emergency department visits. All of this results in positive financial and quality implications for the hospital, the patient and the healthcare system itself.
The discharge process remains a major challenge for healthcare leaders who wants to improve outcomes and reduce readmissions, in large part because patients often don’t understand the instructions. A recent research suggests that implementing follow-up care strategies can improve the process; including treating it more like the admissions process and dispensing medications at that point.
- Coordinating patient follow up and monitoring
Many patients don’t see a physician promptly after they have left the hospital. In fact, 65% of Medicare patients had no interaction with a physician between the time they were discharged and when they were readmitted. This constitutes a significant gap in care for the patient. This gap in care allows health deterioration to go unnoticed by the care team until severe complications arise that requires readmission. Physician follow up is a critical part of the patient’s care plan, but sometimes patients don’t have the motivation to make and keep their appointments. As you build your post discharge follow up programs, appointment reminders and scheduling become key components of a successful hospital readmission reduction strategy. Not only do you need to be able to facilitate the appointment, it’s equally important to educate the patient as to why the follow up is needed.
- Emphasize on care model than business model
Communication with the nurses, when it comes to discharging patients; it was discovered that often kept patients at the facility for longer than medically necessary, recognizing the financial benefits associated with a prolonged stay. The patients really wanted to go home but the care facility won’t let them. The system was driven more by the business model than the care model. That was one of the first things which were identified as a tremendous opportunity to improve upon.
- Educating patients
Another key strategy that payer should follow after patient discharge is to educate patients throughout their hospital stay. Start teaching and educating people from the day they come in, making sure they are prepared to take care of themselves at home.
Every interaction with patients is an opportunity to educate patients, about their condition, medication, post-discharge plans and follow-up plans. Patients that understand more about their condition and their care will feel more involved in their care process and less detached.
To educate patients during transitions of care, such as from the hospital to a long-term care facility or to home, is especially important for the patient experience because understanding what to do post-discharge eases patients’ anxiety. “A ‘cold’ discharge process can leave a patient feeling like a number. Empowering the patient with pertinent information and support tools makes a huge difference.
- Make a positive patient experience
Hospitals where leaders emphasize the importance of patient satisfaction and where staff is trained in patient satisfaction strategies will be more successful. Create a culture that values the patient experience. We have all of our management staff making rounds, talking with patients, talking with families, so they’re close to what the patients are experiencing.
Training staff to adopt a patient-centric approach to patient care can also help hospitals emphasize the importance of patient satisfaction. It is important for a payer to have a perspective to treat each patient like your family member treated, understanding that the hospital which is a common place for the professionals but; it is a unique situation for patients and families. Additionally; hospitals should acknowledge that treating patients goes beyond one individual, as treatment also affects the patient’s family.
- Proactive discharge planning
Usually the care transition processes, discharge planning starts two days before a patient leaves the post-acute care facility, typically between days 20 to day 22. It is important to have a discharge plan made as soon as the patient is admitted to the post-acute facility. This proactive discharge planning identifies the exact number of days the patient should stay at the facility to achieve the desired functional goals valuable information for both payers and the patient’s caregiver or family.
Proactive discharge planning also aids patients’ transition from the skilled nursing facility to their homes by highlighting any non-clinical needs patients might have like feeding or bathing etc. which gives families plenty of time to figure out how to meet those needs, whether themselves or through a home care service.