Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Appendix D. Promising Components and Interventions to Reduce Readmissions

10/29/2013

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TABLE D-1. Promising Components and Interventions to Reduce Readmissions

Comprehensive Discharge Planning
Assess Transition Risks
  • Screen patient for medical & social readmission risks.
  • Standardize risk assessment.
  • Query patient about prior post-discharge period.
  • Initiate planning to mitigate transition risks immediately.
  • Obtain information from primary & community care providers as needed.
Prepare the Patient
  • Identify the primary learner (may be family or other third party).
  • Personalize education.
  • Teach patient regarding condition & recovery (self-monitoring, warning signs).
  • Use teach-back to assess comprehension.
  • Provide patient-centered information to patient & family at discharge for reference (discharge instructions including POC, medications, appointments, contact information).
  • Involve clinical pharmacist in pre-discharge education.
  • Utilize transition coaches & advocates.
  • Assess patient understanding of discharge POC.
Develop Post-Discharge Plan of Care (POC)
  • Involve all disciplines (nursing, social work, clinical pharmacist, etc.).
  • Involve patient & family members.
  • Reconcile medications.
  • Incorporate care events & recovery milestones.
  • Counsel re palliative & end-of-life care as appropriate.
  • Electronically prescribe discharge medications directly to community pharmacy.
Post-Discharge Support and Care
Prepare the Next Provider of Care
  • Identify next provider of care.
  • Standardize format & content of communication to next provider of care.
  • Include post-discharge POC & medication reconciliation.
  • Assign responsibility for communication.
  • Communicate discharge summary to physician responsible for followup care.
  • Use patient as conduit of information to next provider (paper communication, patient-managed PHR).
  • Confirm receipt by next provider of care.
  • Verify common understanding with telephone call to next provider of care.
  • Involve the patient's physician in developing the discharge POC & home care.
  • Utilize a checklist for visits following discharge.
Ensure Post-Discharge Followup
  • Arrange care for patients lacking a regular source of care.
  • Schedule appointments pre-discharge for followup clinician care & testing.
  • Arrange home care/visiting nurse.
  • Implement home care protocols for high-risk patients.
  • Front-load PCP/clinic visits.
  • Front-load home care.
  • Utilize APN with special training in population (CHF).
  • Provide transportation, free followup care (for uninsured).
  • Provide home visit(s) by NP, physician, or multidisciplinary team.
  • Verify visit and/or dispensing of discharge meds.
  • Provider continuity during the transition.
Ensure Post-Discharge Support
  • Post-discharge telephone outreach (NP or clinical pharmacist).
  • Multiple telephone contacts.
  • Provide patient hotline.
  • Utilize transition coaches & advocates.
  • Engage community services.
  • Use tele-monitoring with electronic link to case manager and/or provider to monitor status & compliance.

SOURCE: Metzger J. Preparing for accountable care: Coordinated care. Falls Church, VA: Computer Sciences Solutions Global Institute for Emerging Healthcare Practices; 2012; WA12_0280 HCG.

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