Keeping a Closer Eye on Post-Discharge Planning

Team-based patient outreach fuels success

Regulatory and financial pressures are forcing hospitals to ramp up their post-discharge strategy initiatives.

Some of the pressure is coming from the Affordable Care Act (ACA); Section 2717 requires that hospitals report the results of their efforts to prevent hospital readmissions. Whether it’s patient education and counseling, comprehensive discharge planning or post-discharge reinforcement by an appropriate health care professional, federal officials want to know what hospitals are doing to keep patients out of the hospital—and how many health care dollars are being saved in the process, experts noted.

David B. Nash, MD, the dean at the Jefferson School of Population Health in Philadelphia, said that when it comes to implementing effective post-discharge policies, timing is critical. “Adequate discharge instructions, making sure patients understand every aspect of their medications, getting the medication and confirming that they are taking it as soon as they leave the hospital” are all efforts that have to be put in place as early as possible, Dr. Nash said.

Susan Stinson, the senior vice president of clinical operations at The Lash Group, an AmerisourceBergen Specialty Company, based in Frisco, Texas, said hospitals face many challenges when implementing discharge strategies, particularly regarding staff follow-up with the patient. “It really takes a dedicated team focused on following up [post-discharge],” Ms. Stinson said. “They may not be able to reach the patient the first time they call, and they need to track what the patient’s needs are.”

Charisse Coulombe, vice president of clinical quality for the American Hospital Association’s Health Research & Educational Trust, runs a federally funded project with 1,500 hospitals across 31 states called the Hospital Engagement Network program. “One of the topics that we are looking at with these hospitals is readmissions,” Ms. Coulombe said, adding that the facilities “are very engaged in the conversation and are really looking at and focusing in on what they can do to help prevent patients from coming back to the hospital unnecessarily.”

Ms. Coulombe echoed Dr. Nash’s assertion that discharge starts the day that the patient is admitted. “They’re identifying patients who could be at high risk for readmission and they want to know that up front. They’re doing an assessment on the patient and they’re looking at their age, socioeconomic factors. We want to know if every patient has a pretty complex social system and family support or no family support or if they are homeless.”

There’s Help at Hand

Fortunately, hospitals don’t have to work in a silo when developing care coordination strategies: Several groups have studied the issue and published helpful guidelines and reports.

A case study developed by The Commonwealth Fund, for example, looked at four hospitals with 30-day readmission rates in the lowest 3% among all U.S. hospitals for at least two of three conditions (congestive heart failure, myocardial infarction or pneumonia), reported by the Centers for Medicare & Medicaid Services (CMS) from the fourth quarter of 2007 through the third quarter of 2008. These case studies identified the following best practices:

A focus on improving clinical quality and patient care, with the belief that reductions in readmissions will naturally occur as a result of these improvement efforts.

Attention to discharge planning from the first day of patients’ stay, typically within eight hours of admission. This includes staff assessment of patients’ risk factors, needs, available resources, knowledge of disease and family support. In fact, two of the four hospitals in The Commonwealth Fund report scheduled follow-up appointments for most of their patients prior to discharge. Because of limited resources, the two other hospitals made follow-up appointments on an ad-hoc basis for the neediest patients. All hospitals coordinated with home health agencies and connected patients to community resources.