Nine Lessons about Post-Discharge Follow-Up

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Since 2010 ReInforced Care has been reaching out to patients after hospital discharge to reinforce their discharge instructions, promote their well-being, and inform hospital staff about further patient needs and experiences. Here are nine lessons we have learned through that work – some of which may surprise you.


1. Medication reconciliation is most effective if done in the home as well as in the hospital. Despite the best intentions of providers and patients, omissions are common with inpatient med recs. At-home med recs often turn up duplications between generics and brand-name drugs; dosage discrepancies; forgotten nutritional or herbal supplements; and failure to mention PRNs.


2. Patients forget their discharge instructions. We see it all the time. Even a documented teach-back prior to hospital discharge does not guarantee retention. These instructions need to be reviewed in the days after hospitalization, whether by a medical office, a visiting nurse, a family member or friend, or an outreach program.


3. Just because patients retain discharge instructions doesn’t mean they will follow through. Surprisingly often patients tell us of intentions to replace Coumadin with generous helpings of spinach, Lipitor with vinegar, or insulin with cinnamon. These and other alternatives to mainstream treatment need to be brought to light and discussed. The best approach involves learning about how the patient thinks, considering cultural differences, and getting buy-in—not just telling what needs to be done.


4. Don’t take for granted that each patient can access a primary care physician. Having an assigned PCP does not equate with having real access to one. Patients report that it can be difficult to reach a PCP; get a timely appointment; or afford the copayments. We also hear that sometimes insurance plans assign a patient a PCP without confirming that the doctor is accepting new patients.


5. When patients schedule their own medical appointments, their attendance rate is higher. Hospital staff have lamented to us that their pre-discharge initiatives to schedule follow-up appointments result in shockingly high no-show rates. Our conversations with patients at home show that attendance is quite high for self-scheduled appointments.


6. Patients are willing – in fact, relish the chance – to give feedback when so invited. And not only complaints or praise, but also constructive advice that can aid in hospital improvements. We’ve collected feedback on topics ranging from noisy units to a lack of up-to-date fire extinguishers.


7. Large decreases in readmission rates are rare. In fact, reports of dramatic reductions are often either spurious or exaggerated. As one research team put it, “A single-component intervention is unlikely to have a substantial effect on improving the patient experience or reducing post-discharge adverse events [….]” Do your best to make small improvements that can add up. Small gains can make a surprisingly big difference for individual patients and, in the right patient categories, for an institution’s bottom line.


8. Short hospital stays are not responsible for high readmission rates. In recent decades US readmission rates have been notably flat while the average length of stay has taken a nosedive. Also, recently we conducted a regression analysis of 118,000 patients in Mid-Atlantic states, 2008 – 2014. Controlling for other indicators of severity of illness, if anything it was longer stays that were linked with higher readmission rates.


9. When predicting outcomes, try to supplement clinical judgment with statistical tools. Studies over the past 50 years have usually shown predictive modeling to outperform individual predictions. Perhaps surprisingly, this has been true across professional categories (nurses, attending physicians, residents, etc.) and even regardless of individuals’ degree of certainty about a given outcome.


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