As we read, listen, and engage in meetings, many terminology and buzz words are battled round to characterize the changing health care environment such as continuum of care, collaborative care, care transition, and value-based care. However, the bottom line remains for most health care providers and patients to provide time-efficient, quality care that prevents patients from harm and reduces the responsibility of providers. The hurdle for most health care providers is to recognize and implement processes to streamline transitions in patient care and prevent costly new Medicare readmissions penalties.
Cutting down readmissions from hospitals can be challenging because it depends on many variables. Besides providing high-quality care, providers must empower patients to partake in post-discharge care management and ensure that the condition of the patient does not worsen unpredictably. Healthcare professionals can work with key patient engagement strategies to reduce hospital readmissions, including identifying their high-risk patients, engaging them in the process of care planning, and addressing health social determinants.
Healthcare professionals must, therefore, identify which patients are at the highest risk during the recovery process to succumb to a medical problem. From there, clinicians can aim the highest-needed patients with their commitment efforts. Apart from medical conditions, there are other flags clinicians should look for. Patients with minimal English skills, limited health literacy, receiving conflicting information from providers and exempted from their post-discharge care planning may also be at greater risk of readmission.
Strong involvement of patients in the process of discharge and care managing may not be enough to maintain healthy patients. Patients may not follow the guidelines for post-discharge care or appear for follow-up appointments. That doesn't always mean that the patient doesn't comply; some experts agree. Rather, it may imply that the patient experiences one or more of the health determinants that serve as a barrier to access to health care.
Around these considerations, healthcare organizations can develop their follow-up care plans after discharge. By indulging patients and families during care transitions and taking into account the social factors of health, organizations can strengthen their procedures for follow-up care and lower the risk of hospital readmissions. Cutting down readmission rates in hospitals will remain a high priority as industry professionals seek to limit costs and drive quality of care. Clinicians can reduce the risk of high-cost readmission through using strong patient engagement methods during the post-discharge process.