2.Lengthen the Handoff Process
At every juncture in patient care process, especially discharge, have teams talk to each other about the patient. And by the way, don't call them discharges. Call them "transitions." Standardize them for a variety of providers, from hospital to rehabilitation facility to skilled nursing facility to home and back.
Boutwell says that "taking this person-centered approach shifts the concept from discharge, which is a moment in time and you're done with it, to a transition—a shared accountability. We need to make sure the receiving providers understand who this patient is, with a 360-degree view.
Jencks adds that "senders and receivers, for example hospital discharge planners and skilled nursing facility staff and home health" meet often enough so they can learn about the realities of the transitions they initiate and receive.
3.Provide Medication on Discharge
Send the patient home with 30-day medication supply, wrapped in packaging that clearly explains timing, dosage, frequency, etc. Some health centers with Medicaid patients may be trying this strategy, which is difficult for hospitals to do with Medicare patients because of distinctions between Part A and Part B payment. Still, for some high-risk populations, such as patients with congestive heart failure and those who have been readmitted before, it might be worth it for the hospital to absorb the cost.
4. Make a Follow-up Plan Before Discharge
Have hospital staff make follow-up appointments with patient's physician and don't discharge patient until this schedule is set up. A key is to make sure the patient has transportation to the physician's office, understands the importance of meeting that time frame, and following up with a phone call to the physician to assure that the visit was completed.
We couldn't find anyone using video monitors to communicate on a daily basis with the use of such software as Skype, for example, but some readmission experts say it's an interesting approach to keep up visual as well as verbal communication with patients, especially those that are high risk for readmission.
On a more practical scale, Home Healthcare Partners in Dallas uses health coaches, intensive care clinicians, and wireless technology to record vital signs on a daily basis for about 2100 discharged Medicare fee-for-service beneficiaries for between 60 to 120 days. So far, they have done this for about 7,000 unduplicated patients in the last two years, for several hundred hospitals in Dallas and Louisiana, says HHP's CEO, Wayne Bazzle.
The target population for intense monitoring includes those with four or five co-morbidities and who have a primary diagnosis of congestive heart failure, chronic obstructive pulmonary disease, diabetes, Alzheimer's and hypertension.
Bazzle says that the effort involves phone calls of between five and 15 minutes, and is frequent enough with the same team "so we have their trust. We can help them stay out of the hospital if they're more truthful with us about what's going on, and if we see some deterioration, we can help them cope. Normally it's a medication management issue, or they've become a little too relaxed with their diet."