"When you roll it all up, this is a convergence of educating the patient about their regimen of care, and it is more than just a follow-up with a physician office—it's a disease-focused clinic," Donnelly says.
Lancaster General, too, routinely calls discharged patients within a few days after discharge, depending on the severity of the condition. They've found that the calls reinforce and remind patients of a lot of the education they received while in the hospital.
"When we do these phone calls—even though we spend a lot of time on the discharge process and educate the patients in the hospital, when you call the next day to see how they're doing, we've found in the last review that 60% of the patients had significant questions related to their medications," Casale says. "We learned a lot by that early follow-up phone call and contact with patients."
Keeping patients home with procedural steps
As with Donnelly's mother-in-law, an integral part of keeping patients from being unnecessarily readmitted is by including standardized procedures in the treatment guidelines for when things go wrong.
At UPMC Hamot, all HF patients receive a home health referral upon discharge.
"We have an intensive home health initiative, and we use telehealth whenever we can," Donnelly says. "They get the little scale with the blood pressure monitors hooked up to the phone line, and we review their weight every day."
Lancaster General also has procedures in place with HF discharge patients, including having them record their weight daily and report if they are suffering from any other symptoms, such as shortness of breath. If nurses see that a patient has gained weight too quickly or is having trouble breathing, there are protocols in place for them to adjust the patient's medications and schedule an immediate follow-up appointment in the HF clinic.
"As you'd expect, if you can impact early, you're much more likely to keep these patients from coming back into the hospital," Casale says.
If a IU Health Ball Memorial patient begins experiencing unwanted symptoms after being discharged to an after-care facility, providers on both sides get on the phone.