Reducing Hospital Readmissions with Follow-Up Visits

Friday, January 22nd, 2010
This post was written by Melanie Matthews

Mary Cooley, manager of case and disease management at Priority Health, describes a discharge protocol that is preventing hospital readmissions among patients with cardio vascular conditions.

Our heart failure initiative sprang from our work in 2008 with cardiovascular conditions. Heart failure is one of those top readmission diagnoses for Medicare. We are following the Institute for Healthcare Improvement (IHI) Getting Started for Heart Failure Guide, which says that, “patients must be seen within five days of discharge.” We’re promoting that across our network of providers; the patient is seen in the office to review medications, any early symptoms, the patient’s progress since hospitalization and any questions they might have. We feel that that’s been a key ingredient to our success.

We want to be sure that we empower the patient to be an active participant or an active consumer in their healthcare. We want them to communicate their healthcare concerns and not wait until things get out of hand and an ER visit or an inpatient hospitalization is warranted.

One important concept is to not only discuss the red flags of management and document them in the personal health record (PHR), but to employ “teachback” strategies so that we’re sure that this is all in concert with our health literacy efforts. We want to be comfortable that the patient has heard what we have said, has been able to process that information and has been able to teach that back to us in a way that’s meaningful for them. That will serve them well in managing their condition moving forward.

We also want to not only address current concerns but also anticipate any needs and concerns, and to be proactive. Discuss with the patient that they should talk about their symptoms and any side effects of medication when they see their physician. Not necessarily to stop that medication, but to call the physician first and discuss what’s going on and maybe how that treatment plan can be remedied based on their current effects of the treatment protocols. And also, not only when to call the physician, but who to call. These patients have multiple comorbidities and when they are coming out of the hospital with many different symptoms, they don’t always know who to contact. It’s very important to say who is on first base and who to call when and if you’re having difficulty.

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