Prompt Follow-Up Visits Key to Reducing Avoidable Rehospitalizations

Wednesday, October 5th, 2011
This post was written by Patricia Donovan

Making a follow-up appointment for patients about to leave the hospital is the simplest way to keep that patient from returning to the hospital. Unfortunately, more than half of Medicare patients discharged home do not see a primary care clinician within two weeks of leaving the hospital, according to a new Dartmouth Atlas of Health Care report.

Arranging primary care follow-up after discharge is one of the top tactics reported by respondents to HIN’s 2010 Reducing Readmissions e-survey. One respondent takes this a step further: “Our follow-up appointment is made before the patient leaves the hospital. On the date of discharge, a referral is made to case management. A call to the patient is made within 48 hours, often the day of discharge, and the case manager confirms attendance at follow-up appointment.”

When Geisinger Health Plan launched its medical home initiative in 2007, it found that the hospital-to-home or hospital-to-nursing home transitions offered a wealth of opportunity for intervention, the first being medication management and medication reconciliation. “We realized that we didn’t have discharge information in a timely manner. We realized that there would be discharges home with no follow-through on home health or durable medical equipment (DME) delivery.”

Geisinger took that opportunity to link to ER and admissions census data at community hospitals. “Many community hospitals were very willing to give the practice access to their census list or to a summary so that you could see at least a limited view of the inpatient stay,” explains Doreen Salek, Geisinger’s director of business operations in the Care Transitions Toolkit.

“All those things helped us enhance that transition from hospital to home. Early notification about admission and the ability to see in real-time what was being done — outcomes from some test results, medication changes, etc. — were key things that we realized early on were very helpful in this process.”

The Dartmouth Atlas of Health Care report identified many variations across regions and hospitals:

Overall, 42.9 percent of patients who were released to go home from the hospital after medical treatment had a primary care visit within two weeks in 2009. Patients in New Orleans, La. were far less likely to see a primary care clinician after discharge home, with 25.6 percent having a visit to a primary care clinician within two weeks of medical treatment in a hospital, compared to 61.4 percent of patients in Lincoln, Neb.

Among academic medical centers, the range of variation was somewhat higher. Less than 20 percent of patients discharged from New York University Medical Center in Manhattan, N.Y. saw a primary care clinician within two weeks of a medical discharge, while the rate was nearly three times higher at the Mayo Clinic’s St. Mary’s Hospital in Rochester, Minn.

These findings highlight the pervasive problems with patient care after hospital discharge, and underscore the importance of primary care systems in reducing avoidable hospitalizations.

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