Readmissions can end up costing your hospital a considerable amount in financial penalties under the Hospital Readmission Reduction Program. Ensuring that you have effective ways to reduce the risk of readmissions can help you avoid these penalties.
Having a hospital readmissions checklist to refer to provides you and your staff with the information needed to help patients receive timely follow-up care and keep primary care physicians aware of these patients’ condition and medical needs.
1. Determine the Risk of Readmission
After patients are admitted, begin determining their risk of readmission based on factors such as their medical history and underlying problems that could affect their condition. Consider lifestyle factors that could also increase the risk of readmission, such as smoking, and social determinants such as lower income, education or access to healthcare facilities. Implement relevant interventions during the patient’s stay in order to reduce the risk of readmission.
2. Provide Complete and Accurate Discharge Information
Provide patients and caregivers with detailed discharge information and post-hospital visit instructions in printed form. Go over this information to ensure that it has all of the details that patients and caregivers need, such as when to seek follow-up care and warning signs to watch out for.
Recognize that this is a vulnerable time for patients and their families, and remembering important information may be challenging. Prepare to follow up with the appropriate information after the patient has left the hospital to facilitate recovery (more on this in Point 8 below).
3. Reconcile Patient Medications
Note medication types and dosages that patients currently take upon admission and accurately note any changes to these medications during their visit. Note whether any new types of medication are needed for the patient’s condition. Provide patients and caregivers with updated information on medications, including types, dosages and potential interactions. Medication adherence will need to be monitored and encouraged, which also requires ongoing patient engagement after they leave the hospital.
4. Schedule Follow-up Care
Assist patients with setting up follow-up appointments with their primary care physicians. Schedule any additional testing or lab work that is needed. Provide patients and caregivers with printed information on these appointments. Provide information on why this care is needed and emphasize the importance of going for follow-up care, which helps reduce the risk of readmission.
5. Communicate with the Primary Care Physician
Communicate with the patient’s primary care physician to ensure proper follow-up care. Information to communicate includes the reason for the patient’s hospitalization, recommended timing for a follow-up appointment and any concerns that should be addressed during this visit.
6. Address Patient Concerns or Problems with Follow-up Care
Assist patients with finding a primary care physician through Medicare, Medicaid, their health insurance provider or other resources if they do not have one already. Offer assistance with transportation if patients do not have a reliable way to get to and from follow-up appointments with their primary care physician. Provide patients with contact information for after hours care if they have any concerns about their condition that cannot wait until regular office hours.
7. Ensure Patient and Caregiver Understanding
Use the teach-back method to ensure that patients and their caregivers understand instructions for follow-up care. This method involves asking patients and caregivers to explain these instructions in their own words. Offer more detailed explanations if needed, and answer any questions patients or caregivers have. Patients should also receive education on their condition, including symptoms to watch for, ways to self-manage the condition through lifestyle modifications and when to seek emergency or non-emergency medical care.
8. Contact Patients Within 48 Hours
Call patients within 48 hours after they have been discharged to check on their condition, address any concerns they have and go over follow-up care instructions once again. Contacting patients can also serve as a reminder about their follow-up appointment with their primary care physician or reminders about any lab work or testing they need to have done.
Ideally, this engagement would extend beyond 48 hours, but manual phone follow-up is resource intensive. Fortunately, there is a much more efficient and cost-effective way to engage patients in an ongoing manner post-discharge.
Using an automated, digital patient engagement platform such as PatientBond can help your hospital check off many of the items on this hospital readmissions checklist. That’s because it uses psychographic segmentation and adaptive technology to manage discharged patients based on their own unique motivations and attitudes related to health and wellness rather than a one-size-fits-all approach.
Psychographics pertain to people’s attitudes, values, lifestyles and personalities, and are the key to their motivations, priorities and communication preferences. Messaging that is personalized to patients’ psychographic profiles resonate more strongly and enhance outcomes. This is why PatientBond has driven up to 90 percent reductions in readmission rates for medical issues such as Congestive Heart Failure and spinal surgery.
PatientBond also makes patient communications timely and more convenient through different means, including Interactive Voice Response, text messages and email. If you’re struggling to check off everything on this list, it may be the solution you’re looking for.