Hospital readmission prevention programs, such as the one my Accountable Care Organization (ACO) conducts, try to make sure the patient coming home from the hospital fully understands their discharge instructions and removes any roadblocks that would prevent the patient from following those instructions.

With our program one of our nurse Care Coordinators contacts the patient within two days of discharge from the hospital.  They make sure the patient sets up an appointment to see their physician within 1-2 weeks and, most importantly, review the Discharge Instructions the patient was given upon discharge from the hospital.  Basically, there are 4 areas that are covered:

• New Or Worsening Symptoms (NOWS) – The Care Coordinator  asks the patient how they are doing to determine whether they may be feeling worse than when they were in the hospital, either due to worsening of known symptoms or the development of new ones.  In my experience, it never ceases to amaze me how often patients minimize such worsening in their condition and delay contacting their physician.  Directly asking about NOWS helps identify their occurrence and teaches the patient their importance and the need to inform their doctor immediately when they are present.
• Medication Reconciliation – Have there been changes made to the medications the patient was taking before entering the hospital?  The Discharge Instructions that the patient was given before discharge include a list of the medications they should take, but often questions arise once the patient is home.  The Care Coordinator   goes over the discharge medicines with the patient and compares those to the ones the patient was taking before.
• Appointment Adherence – Has the patient made follow-up appointments that have been recommended so they continue to recover?  These could be with specialists seen in the hospital as well as the primary care physician.  In addition, certain testing may have been recommended as well.  These are usually specified in the Discharge Instructions, too.
• Self-Management – Are there things the patient was instructed to do to help their recovery?  If they had surgery, how do they manage the dressings of the surgical site?  If they are a diabetic, do they need to check their blood sugars more frequently than before the hospitalization?  What about their activity level and diet?

In each of these areas, the Care Coordinator makes sure that the patient knows what to do and has no obstacles to carrying out their discharge instructions.  Each day our 22 Care Coordinators reach out to dozens of Medicare beneficiaries who have been discharged from the hospital and, thanks to their efforts, miscommunications are corrected and problems solved on a daily basis to help these patients complete their recuperation at home.

For Your Health – Dr. Bob