Elevating discharge: A critical factor in preventing readmissions while improving the patient experience

Wayne Sensor, Chief Executive Officer, Ensocare

With risk migrating from payers to providers, hospitals can no longer afford to cut ties with patients at discharge. Instead, they should actively transition individuals to appropriate post-acute care settings and continually track and assess risk to ensure patients do not return to the hospital unnecessarily. 

By enhancing discharge, hospitals not only can prevent avoidable readmissions and impact outcomes, they can also improve the patient’s experience and satisfaction. Additionally, well-honed discharge processes can mitigate penalties while boosting workflow efficiency and overall care quality – ultimately protecting an organization’s bottom line. 

Though making the discharge effort more robust and interactive typically hasn’t been a priority for organizations, it is becoming increasingly important given today’s healthcare environment. 

Hospitals that employ the following best practices can enable a reliable and consistent discharge and post-discharge experience for patients, their families and staff. 

Deliver regular and targeted patient and family education

To lay the groundwork for an effective discharge, hospitals should develop a strong education program that engages patients and their families early and often to ensure they truly grasp the patient’s condition. Being a well-informed care participant can increase a patient’s chance of positive clinical outcomes post-discharge, while also enhancing satisfaction. 

Before leaving the acute setting, patients and their families should understand the diagnosis, the patient’s expected condition at the time of discharge and the prognosis, in addition to the medications, treatments or therapies included in the care plan. They also need to appreciate their roles in keeping the patient on the path to recovery. 

By improving not just what information is provided but how it is delivered, hospitals can take their education programs to the next level, making post-discharge care more successful. For example, it is not uncommon for patients to receive paper packets about their condition or care plan prior to departure. Although these packets contain a great deal of information, delivering it in this fashion can be overwhelming to the patient, particularly if he or she has been prescribed new medications or has comorbidities which further complicate the condition. Additionally, it’s difficult to know whether the patient understands or even reads the information conveyed in this manner. 

By providing education in different and more meaningful ways, such as during in-person teaching sessions, through videos, or via other communication modes like mobile devices, portals or over the phone, hospitals can be confident patients fully comprehend the message. Furthermore, enlisting best practices such as the “teach-back” method helps hospital staff reliably assess understanding. 

Seek optimal post-acute placement

Placing patients in the most appropriate post-acute location can ensure they receive optimal care when they need it. By leveraging care coordination and discharge technology, organizations are better equipped to efficiently and accurately match patients’ needs with receiving facilities’ capabilities and services. 

For example, if a patient requires physical, speech and occupational therapy following a stroke, discharge technology can be used to identify potential post-acute providers capable of meeting the patient’s needs. Because these can be extensive and include not just clinical requirements but also psychosocial preferences, using technology makes the matching process much more streamlined and precise. This technology also allows hospitals to provide a targeted list of possibilities to families, informing and aiding decision-making in moments rather than hours or days.

To optimize care coordination and discharge planning technology, hospitals should start discharge planning early – at the time of admission, if possible – ensuring enough time for adequate communication and decision-making amongst the family, hospital and receiving facility.

Smoothly transition clinical data

Supplying meaningful information related to the patient’s condition is key for providing proper care. Whether paper-based or in an electronic format, there’s no doubt health records contain a wealth of information about the patient’s condition and health history; however, comprehensive records can be unwieldy and may even contain irrelevant or out-dated information. 

For many hospitals, supplying the most relevant information in a timely fashion to a receiving facility can be challenging. But not doing so can delay the administration of necessary medications, treatments or therapies – potentially impacting patient outcomes. 

Using discharge technology, hospitals can extract pertinent information directly from the patient’s electronic health record (EHR) and automatically deliver it to a receiving facility before a patient is transferred, preventing the receiving organization from having to review dense patient records while also allowing the organization to ready prescriptions, treatments and therapies per the care plan. 

Continue to stratify risk throughout the care continuum

Risk stratification involves assessing and responding to a patient’s risk for returning to the hospital after discharge. Because risk can increase or decrease as patients reach or miss health milestones, hospitals should stratify risk throughout the care continuum – rather than solely upon discharge – and address the changing dynamics of the patient’s condition. 

Certain conditions, such as hip surgery, congestive heart failure and chronic obstructive pulmonary disease are more likely to result in readmission, and it is especially important to monitor these patients’ recovery so the hospital can detect when a patient misses milestones and proactively deploy interventions before the patient returns to the acute setting. 

To begin stratifying risk and tracking patients, hospitals can leverage an EHR or other technology with risk stratification capabilities. They should then identify each patient’s preferred communication method and use it to stay connected with the individual, family and/or post-acute facility. Hospitals can also use automated reminders or other outreach strategies to obtain updates as needed. 

Refining discharge yields better results

As healthcare continues to evolve, hospitals need to embrace targeted processes that facilitate patient discharge. Moreover, they must employ methods for monitoring patients after they leave the hospital, allowing organizations to intervene when readmission risk increases. 

By elevating and automating the discharge effort, hospitals not only can prevent unnecessary readmissions and ensure patients are transferred to settings capable of meeting their clinical and psychosocial needs, they can also vastly improve the patient’s experience, satisfaction and outcomes while securing the organization’s financial health.

discharge, Ensocare, family education, patient education, patient engagement, reducing readmissions


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