For heart failure patients making the transition from hospital to home, an effective discharge summary can mean the difference in whether the patient recovers quickly or returns to the hospital, according to two new studies from Yale School of Medicine researchers. To be effective, discharge summaries must have three key factors: they must be timely, be quickly forwarded to the outside physician, and contain detailed and useful information.
Here are some best practice approaches for hospital discharge communications from respondent's to HIN's fourth annual Reducing Hospital Readmissions Survey.
- Follow-up with patient post-facility discharge by case managers embedded in our physician practices.
- Improved communication between inpatient (hospital) care coordination and outpatient (medical group) services.
- Follow-up appointments with the doctor and home care arrangements are made prior to discharge from the facility if appropriate. Discharge information with medications are sent to the doctor’s office by the facility doctor on discharge for availability on follow-up appointment.
- Increased oversight of high-risk patients; increased communication among clinical teams and health providers.
- We utilize a transitional care program to engage with patients while in facility and continue to follow with in-home visits on discharge to continue education and teach-back as well as monitor and oversee progress.
- Post-acute touch (home health) within 24 hours of discharge; medication reconciliation, signs and symptoms education and scheduling primary care physician (PCP) office visit appointment.
- All discharges are called by our nursing supervisor or other designee to determine their post-discharge status and ensure they keep their follow-up primary care appointment.
- Reaching the patient within one to two days post-discharge. Assuring the patients have a follow-up appointment and transportation, understand discharge medications, red flag symptoms and who to call if necessary.
- Follow-up in the home for 35 days post-transition to home.
2014 Healthcare Benchmarks: Reducing Hospital Readmissions documents the latest key initiatives and partnerships to reduce readmissions by more than 100 healthcare organizations.
This 60-page report for the first time provides details on partnerships with post-acute care to reduce readmissions from these care sites.
For more information or to order your copy today:
This market research on current and planned programs to reduce readmissions is supported by more than 50 charts and graphs assembled from responses to HIN's fourth annual survey on Reducing Hospital Readmissions.
If you are already a Healthcare Intelligence Network Benchmark subscriber, then this report is FREE for you.
Not a member, but want to receive all of our benchmark reports for one year for just $695...a $500 savings! Simply sign up for HIN's Benchmark Subscription, and you'll get access to these readmission benchmarks and upcoming benchmark reports on embedded case management and more. Click here to sign up for this limited time offer today:
New in the 2014 edition:
- Comparative 2010-over-2014 data on key activities, including efforts targeted at patients with diabetes, UTI, asthma or undergoing hip or knee replacements;
- Benchmarks on identification/assessment of high utilizers and individuals at high risk for readmission;
- A look at partnerships with post-acute care: trends in collaborations with home health, hospice, and skilled nursing facilities (SNFs) and results from these partnerships;
- New metrics on most successful strategies for readmission reduction, from inpatient coaching to telephonic monitoring;
- Sector-specific data from hospitals and health plans on programs, processes and outcomes; and
- Continued planning in light of ongoing payor scrutiny of 30-day readmissions.
This benchmarks report is designed to meet business and planning needs of hospitals, health plans, managed care organizations, physician practices and others by providing critical benchmarks that show how the industry is working to reduce rehospitalizations.
This report provides expanded data on:
and much more.
Current and planned readmission reduction programs;
- Populations and conditions targeted by readmission reduction efforts;
- Tools and strategies to identify patients most at risk for returning to the hospital;
- Strategies, protocols and workflows to help prevent hospital readmissions in vulnerable populations;
- The top tasks performed at hospital discharge to minimize the chances of a patient returning to the hospital as well as other strategies to strengthen the hospital discharge process;
- Roles and responsibilities in readmission avoidance program administration;
- The latest metrics on reimbursement trends for 30-day readmission rates;
- Overcoming barriers to reducing readmissions;
- The impact of hospital readmission management programs on healthcare utilization, member/patient satisfaction and ROI;
- The complete December 2013 Reducing Hospital Readmissions survey tool;
For more information or to order your copy today, click here now:
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A multi-user license will provide you with the right to install and use this information on
your company's computer network for an unlimited number of additional workstations within
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P.S. -- You may also be interested in these resources on reducing readmissions: