Improving Outcomes for Post-Acute Patients after Hospital Discharge


Readmission to hospitals within 30 days post-discharge is common among elderly patients who are discharged to a post-acute setting. Although sometimes unavoidable, are there measures that can be taken to prevent unnecessary readmissions? 


A study presented by Harvard Business Review found that on average, a hospital could reduce its 30-day readmission rates by 5% if it simply prioritized communication with patients while also complying with evidence-based standards of care.

Develop a Communication Workflow

To best ensure a patient does not risk unnecessary readmission, develop a discharge process that incorporates a detailed communication workflow for following up with patients. Included in this workflow, should be a protocol for conducting patient follow-up calls to assess the patient’s condition and their compliance with discharge instructions.

Where is the patient being discharged to? Be sure to tailor the discharge process to meet the needs of each patient. If the patient will be going home with family, you will want to develop a more extensive communication plan than if they are being discharged to an assisted living facility.

Consider building in a follow-up schedule based on where the patient is discharged to. For example, if the patient is discharged to their home with Home Health, build a workflow that incorporates a follow-up call on their second day home to check if the home health agency has visited. Follow up with another call one-week post-discharge to ensure the patient's condition has not worsened and there are no signs of medication side effects. Additional calls can be scheduled for 3 weeks and 30 days post-discharge to ensure ample communication with the patient should a concern arise.


Ask the Right Questions

The goal with a post-discharge follow-up workflow is to first off, ensure the safety and well-being of the patient, but second, reduce potential readmission by addressing the patient's concerns as quickly as possible. The following sample questions will help you to better understand how the patient is doing post-discharge and if there is any risky behavior that should be addressed.

Does the patient have a follow up appointment scheduled with his/her physician?

Studies show that patients have a higher risk of readmission during the intermittent time of hospital discharge and their follow up appointment with their physician. Having an appointment scheduled is essential for ensuring that the open channel of communication continues and provides patients the opportunity to voice concerns that can be easily addressed.

Does the patient understand their post-discharge instructions?

One of the largest contributing factors in hospital readmission is inadequate communication between the patient and their doctors at the time of discharge. Engaged and informed patients are much more likely to understand and follow their discharge instructions correctly, making it less likely they will need to be readmitted. Ensure that the patient fully understands the discharge instructions they were given prior to leaving the hospital. Clarify that they know what to do in the event of an emergency or how to contact their physician for issues that are important but are not an emergency.

Is the patient compliant with the medications prescribed at discharge?

Among the most important questions to incorporate in the workflow, are questions regarding the patient's adherence to post-discharge medication instructions. Often times, a patient may not realize that they are being prescribed a new medication or a dosage has changed. When discussing the patient's post-discharge medication, be as thorough as possible. Was the patient provided with an updated list of all medications they should be taking post-discharge? Does the patient have all of their prescribed medications? Is the patient experiencing any unusual side effects from their medication?

Implement Appropriate Next Steps

When addressing patient concerns, be prepared to take action to ensure the patient receives proper care. If the patient does not have a follow-up appointment scheduled, help the patient schedule an appointment or find the patient a doctor that meets their follow-up care needs. If the patient has questions about their discharge instructions, clarify as best you can.

In some instances, escalating concerns for at-risk patients to their clinician is a critical part in facilitating appropriate care. Have a process in place to connect patients to the appropriate healthcare resource.

Available Resources

Click here to download a post discharge follow-up worksheet for post-acute care. Enquire CRM has a configurable template to integrate the forms and workflows in the post-discharge worksheet. Contact us today to set up a demo!







Join our Newsletter