Reducing hospital readmissions within 30 days is a considerable priority in health care, leading to increased patient satisfaction and improved outcomes.
To do this, it’s essential to identify patients who may not understand their transition of care instructions, including necessary follow-up care and changes to their medication regimens, and to provide targeted post-discharge transitions of care interventions.
Effective transition of care interventions should prioritize timely follow-up and patient education.
Timely follow-up
Follow-up that is absent or delayed too far beyond the window immediately following a patient’s transition out of the hospital can be a significant factor in the occurrence of 30-day readmissions. Some examples of timely follow-up that can help avoid these early readmissions include:
- Communication from the patient’s primary care physician, such as reaching out to schedule a follow-up appointment
- Follow-up phone calls from any member of the patient’s care team
- Home visits, when appropriate
- Medication reconciliation/review to ensure that the patient’s medications are being used and monitored appropriately
Patient education
It’s critical to make sure the patient has a solid understanding of their transition of care plan so they can take the correct steps to avoid adverse events and readmissions. An integral component of transition of care patient education is medication management; Point32Health strongly encourages providers to review these patients’ medication lists with them to ensure that the lists are accurate and they have the correct prescriptions.