"It's becoming more evident that quality of care transitions affects readmission rates," notes Judi Sant, RN, BSN, director of medical/surgical at McKay Dee Hospital. "So when patients leave the hospital, coordination of care must extend beyond the hospital's doors and to the next site of care."
This is why prior to the patient's discharge, the team assesses each patient's needs and level of at-home support, then researches available resources, The team schedules follow-up appointments for patients prior to discharge and calls patients to touch base within 24-48 hours of care.
Patients are given a clear treatment plan, which is explained to them and all providers involved in the patient's care are made aware of the plan. All high-risk patients are discussed by the care coordination team during team meetings, so treatment plans and next steps can be put in place.
In taking this approach, Trask notes, "The patient is more likely to get the follow up care necessary and to comply with our recommendations for treatment."
"This approach is good for the patient, but it's also creating cost savings. We have a better plan and our patients are better prepared for discharge and that ends up giving us more virtual beds," However, the most important part of our multi-faceted approach is the successful outcomes and low readmission rates for our patients," says Sant.