Typically, hospital discharge processes are not created with a patient's perspective in mind. By incorporating feedback and working with patients before and after discharge, the discharge process can be vastly improved, particularly in reducing the number of avoidable hospital readmissions.
4.4 million hospital readmissions cost the nation $30 billion each year, and reducing readmissions is a top priority. Patients who are well educated on how to take care of themselves after discharge are less like to be readmitted.
Multidisciplinary discharge planning at the bedside takes place at St. Mary’s Medical Center in Maine. The care team includes nurses, a physician, a case manager, a social worker, a physical or occupational therapist, and a pastoral care team representative. A nurse gives a brief presentation to each patient with input from the care team, including the patient. This approach is a shift from traditional discharge planning, which occurs behind closed doors without patient input. Tammy Joly, RN, BSN, says, “It gives (patients an) additional opportunity to understand the diagnosis they are dealing with.” Survey results show that most patients feel that in addition to having an opportunity to participate, they also were given an active role in their plan of care.
The Cleveland Alliance used a collaborative approach to reducing readmissions that knits together hospitals as well as individual patients. Caseworkers’ roles are re-conceptualized as “transitional coaches” responsible for establishing relationships with patients while they are in the hospital and scheduling follow-up appointments before discharge. The pilot was successful, with only one readmission within 30 days. Since then, the program has expanded.
An Oregon Alliance initiative aims to reduce avoidable readmissions by using coaches who encourage patients to take an active role in managing their own care. Coaches make home visits and follow-up phone calls to address medication reconciliation, signs and symptoms for patients to monitor, follow-up appointments with primary care providers or specialists, and personal health records.
What are some ways consumers can help improve health care?
Leadership positions and health care activism are a good start
What are the benefits of getting patients involved in my efforts to improve care?
Perspective, credibility, and much more...
What are the differences and similarities between consumer advocates and individual consumers?
Organizations need both to be successful.
How do consumers define fair benefit and network designs?
Freedom of choice is one important factor.
What are the benefits of personal health records?
They can help consumers and providers.
Where should I incorporate consumers into my practice or hospital?
Learn from AF4Q examples.
- Why do consumers need to know how much things cost?
- How do we help employers maintain their interest and energy in our partnership?
- What role do employers play in improving care quality?
- What frameworks can I use to engage and activate consumers?
- What are the benefits of personal health records?
- What is the Consumer Engagement Leadership Consortium?
- Where should I incorporate consumers into my practice or hospital?
- How do you explain the idea of “high-quality health care"?
- How do I clarify my role as a consumer within my organization or Alliance?
- How do I become a better consumer leader?