Getting patients back in for follow-up appointments within five to seven days of hospital discharge is key in preventing unnecessary readmissions, explains Irene Zolotorofe, administrative director of clinical operations at Bon Secours Health System.
Medication reconciliation is also a crucial step when patients are discharged, and nurse navigators are advised to report any potential red flags that might result in their readmission.
Of course, the big focus for us with any patient post-discharge or with telephonic calls is whether they understand their discharge instructions. We do the medication reconciliation with them; that’s the most critical element. When they do the review, does the patient understand their medications? Why are they taking their medications? What are they taking? We go line by line with them through their medications and make sure they understand the medications they are taking.
If at any point during that conversation we feel that the nurse navigator and the patient need to meet to do medication reconciliation, we’ll either bring the patient into the office or go out and see the patient. Or we will use one of the resources available to us to make sure that the patient is able to correctly take their medication.
The other piece to this is whether they able to afford their medication. What kind of labs do they have post-discharge? What are those follow-up appointments? We make sure that we help that patient navigate through the system.
We also try to determine whether they understand the red flags for discharge. When do you need to call the doctor? When do you need to call the nurse navigator? Then, bringing that patient in for that follow-up appointment is critical in making sure that we can get them to us. Usually our follow-up appointments occur from between two and five days following their hospitalization. If it is a specialty practice, we follow the guidelines of that specialty practice, but for the most part, with any post-hospitalization we are trying to get them in within that first seven days of discharge.
Essentials of Embedded Case Management: Training, Case Loads and Technology for Practice-Based Care Coordinators documents the experiences of Aetna and Bon Secours in the recruitment, education, workload management and IT support of practice-based case managers.