“During that conversation, we will ask the patient what the information is and we’ll identify any misunderstandings they may have,” says Vish. A nurse will make a follow-up call one to two days later to review the physician’s instructions again, verify that the prescriptions have been filled and are being taken as instructed, and confirm that follow-up visits have been scheduled/completed.
“We ask the patient how they are doing and if they have any symptoms. We review medications and we act as a liaison for the physician,” Vish says. “We reinforce the process by having a structured discharge instruction sheet, which we use for all diagnoses.”
Discharge plans are created and discussed by the teams during subcommittee meetings.
“It is critical to the success [of this program] to create tools that everyone uses and [that] keep us all on the same page,” adds Wheelan. The team at Baylor also created a universal medication list that patients could supply to their physicians so both the hospital staff and the patients’ outpatient treatment providers could be working together.
“Different patients require different levels of service. Some require more dietary counseling, others more education about medication, others more coordination assistance with their primary care physician, cardiologist, or general physician. Our resource team makes sure the process is seamless, and this results in better outcomes,” he explains.
Keeping patients abreast of all that’s involved is only half the equation, however. The other half entails keeping the Baylor team members apprised of how they are doing and making sure they understand their accountability.