What role do consumers and patients play in reducing readmissions?

Knowledge and skills can make the difference.

Once home from a hospital, millions of people each year find themselves readmitted within 30 days. While some hospital readmissions may be necessary and appropriate, many are avoidable and serve as indicators of poor care, poor coordination of care, or inefficient use of health care resources.
In addition to steep personal costs of readmission, there are heavy costs to society, and reducing them is a national priority for improving health care.
The York-Adams Care Transitions Coalition in Pennsylvania found three main reasons for readmission: confusion over medications, unclear discharge instructions, and lack of follow-up from a primary care practice. Now, a health coach helps discharged patients take charge of their conditions, monitor prescriptions, and schedule follow-up appointments. Coaches also help consumers with self-care, such as sticking to discharge instructions or setting exercise and nutrition goals for managing diabetes.
One of the Oregon AF4Q Alliance’s initiatives uses coaches to encourage heart failure patients to take charge of managing their care after discharge. The initiative includes home visits and follow-up phone calls with coaches who address medication reconciliation, signs and symptoms for patients to monitor, follow-up appointments with primary care providers or specialists, and a personal health record.
The RARE (Reducing Avoidable Readmissions Effectively) Campaign in Minnesota addresses contributing factors to readmissions such as patients or caregivers not having enough information for self-care at home, uncoordinated post-hospital care, poor transmission of hospital records, and preventable medical complications. It relies on comprehensive discharge planning, medication management, patient and family engagement, transition care support, and transition communications. Since 2011, RARE has prevented 3,603 readmissions, translating into 14,412 more nights of sleep out of the hospital, less stress on patients and families, and better coordination of care.
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