Follow up with patients after discharge

by Zack Budryk

If healthcare leaders want to prevent readmissions, they must think of their patients as their responsibility even after they leave their hospitals.

As part of their education plan, Project RED has nurse discharge advocates follow-up with their patients after discharge. These interventions, which basically are an opportunity for patients to tell the advocates how they are doing, have helped reduce readmissions by 30 percent, according to Christopher Manasseh, M.D., a researcher with Project RED, in an interview with FierceHealthcare for the Population Health Management eBook.

The 87-bed William S. Middleton Memorial Veterans Hospital in Madison, Wis., has a similar follow-up call system that focuses on medication adherence for high-risk elderly patients. It has resulted in 11 percent fewer readmissions and an estimated savings of $1,225 per patient. And follow-up calls to congestive heart failure patients discharged from Charleston (W.V.) Area Medical Center led to 25 percent fewer readmissions among patients who answered the calls. These cases echo similar research showing that at least in the case of heart failure, following up with a familiar physician reduces readmission and mortality rates.

Sometimes effective follow-up requires more than just phone calls. Sacred Heart Hospital, a 250-bed center in Eau Claire, Wis., has both a case management department that makes sure patients are able to care for themselves after discharge and a county transition coordinator who helps patients with problems such as lack of transportation, according to hospital resource director Julia Lyons.

And while you're following up, take a minute to consider what might bring patients back to the hospital in the first place. Click on the links below to continue reading the special report. 

Follow up with patients after discharge