How pre-discharge communication with patients can prevent readmission

In the era of chronic illness and historically long lifespans, patient care transitions to home or another facility have become commonplace. Unfortunately, what lies between these exchange points is a kind of gray area, a healthcare limbo where risks for lapses in communication, coordination, quality, and safety are at their highest. The result, too often, is that patients lose the level of care management they need, which can result in a return trip to the hospital or worse.

Additionally, provider organizations are left vulnerable to considerable financial penalties for failing to reduce preventable readmissions – a key goal in the shift to value-based care. In a notable example, the Centers for Medicare & Medicaid Services’ (CMS) Hospital Readmissions Reduction Program docks hospitals with a 3 percent reduction in Medicare payments for high rates of 30-day post-discharge readmissions for a defined set of diagnoses. According to some estimates more than 2,600 of the 3,400 hospitals subject to the program will be penalized by CMS in 2016.¹

One very effective way hospitals can assure transitional care success is to engage the patient in discussions about the imminent transition while the patient is still in the hospital. Read on for the top discussion points and strategies.  

Laying the groundwork prior to discharge

A crucial step in planning communication prior to the patient’s discharge includes evaluating his or her cognitive skills. A few key determinations the provider needs to make include:

• Is the patient able to understand instructions from a care coordinator and effectively answer questions about their health and make arrangements for transportation to their follow up appointment?

• Who will be handling the communications on behalf of the patient? Will it be the patient themselves or someone else?

This cognition assessment is important, because if the patient demonstrates that they are not capable of handling post-discharge communication, then a proxy will have to be identified. This proxy will be the one that will act on behalf of the patient with the care coordinator.

With the patient facing the provider, it is the ideal time to capture permission to discuss the patient’s health and also the preferred means of communication from the patient or proxy. This might even include the best time of day to call, the preferred method of communication, and the frequency of communication.

Basic health literacy also is important. Train the patient to identify red flags in their health. Teach them how to communicate these red flags to their care coordinator. Engage the patient to make them a proactive advocate in their health evaluation, rather than a passive participant that might let complications linger.

Finally, before discharging the patient, schedule their follow-up TCM appointment. Communicate the date and time of the appointment to the appropriate contact, as well as the channel (i.e., text, home phone, e-mail). Take this time to also inquire as to whether transportation or obtaining medication prescriptions will be an issue. Arrangements to address these issues can be made as the policies of the hospital allow.

Capture patient preferences

The key to effective outreach is to communicate to patients using their channel of choice. Fortunately, most EHRs today support the capture of patient communication preference. However, it is important to remember to verify and update this preference as part of the pre-discharge process, based upon their current capabilities. For example, can a patient that prefers email actually get to and operate a computer?

It is smart to collect expressed consent and HIPAA waivers from patients and care proxies in order to protect the provider and the organization. This step safeguards the healthcare organization against any concern of violating TPCA or HIPAA when making an outreach. By capturing channel preference, time of day and so forth maximizes the engagement with patients.

Conclusion

Consistent, multi-faceted patient engagement is the optimal way to mitigate hospital readmissions and facilitate care transitions. Start communication as early in the process as possible, and be mindful of patients’ communication preferences. Of course, the need to maintain communication with patients will only heighten post-discharge, which is the topic of our next article in this two-part series on successful care transitions. To download a white paper on “Six Communication Best Practices for Transitional Care Management” click here.