Strategies for supporting patients after transition

Neil Gulsvig
Neil Gulsvig

Post-acute providers who want to be the provider of choice recognize that the emerging face of healthcare demands successful transitions and positive post-discharge outcomes. But how can we measure the effectiveness of our transition planning processes and how do we know that our patients are monitoring and managing successfully after they leave?

These questions lead us to the final driver in our article series, “Seven Key Drivers of Successful Patient Transitions,” If you've missed any of the previous drivers, now is the perfect time to go back and review. Otherwise, our seventh and last driver is post-transition follow up.

Why is post-transition follow up so critical? First, it helps organizations drive better outcomes for patients. Knowing how your patients are doing after their transition from your care is critical to driving reduced rehospitalizations while encouraging improved satisfaction. Additionally, skilled nursing providers who can offer their consumers a patient experience and outcomes that outshine the competition increase their perceived quality and value, and earn a leg up on attracting and retaining patients.

Where can you start? Making timely follow-up calls to patients or families after discharge is one strategy to positively impact your short-stay business. Maintaining positive relationships with patients and families after discharge can enhance the patient experience and secure a lasting emotional connection. That connection will likely lead them to look to your organization for care and services again if they need them in the future. It can also help you identify potential barriers to success for your patients once they are home. By connecting with patients post-discharge, you have an opportunity to provide early intervention on issues that may lead to readmission.

A review of studies of various discharge and post-discharge interventions found that of the programs that were successful in decreasing hospital readmission rates, the majority involved a multi-faceted intervention approach. It is not clear that any one approach alone has a direct impact on readmissions. Follow-up telephone call interventions alone have yet to regularly demonstrate a trend towards fewer hospital readmissions, but the literature suggests that they do improve timely follow-up with primary care providers, a critical component of post-discharge care. Follow-up calls, when combined with other key transition management interventions, have greater potential for positively impacting emergency department visits, readmissions and health-care costs.

Checking in on patients and their families after discharge allows you to identify any barriers to safe and successful transition that were not previously identified and make additional referrals. Perhaps the patient is not able to make meals as previously thought. A timely referral to a meal delivery program and home health services may prevent complications or adverse events that could lead to rehospitalization.

Knowing how your patients do after they leave helps you evaluate your current transition management systems and processes. Has the individual required unplanned medical interventions since they left, such as an urgent physician visit, ED visit or readmission to the hospital? Was the patient education they received helpful and are they applying what they learned at home?  Were the discharge instructions you taught them and sent home with them clear?

Monitoring the effectiveness of key components of your transition management program will help you quickly identify any weak links in the process and take action to continuously improve. Measuring outcomes to support quality care and services arms you with data you can use to secure your position as a preferred provider in your marketplace and with acute care, physician group and payer partners.

Take action

How do you get started? Consider these strategies:

  • Formalize your system for follow-up calls with input from staff, patients and families
  • Explain follow-up process to patients and families before discharge; gather contact information and necessary permissions to speak to proxy if needed for calls
  • Ensure callers are prepared for calls by reviewing patient history, discharge summary and transition plan of care
  • Make a first call within 48 hours of discharge

By developing a follow-up plan and strategy, your organization can enhance patient experiences, monitor patient progress after discharge, provide additional support and referrals, and gather critical data to demonstrate the quality of your care and services. As with all of the drivers we have discussed in this patient transition series, post-acute providers who want to be the provider of choice need to recognize that the emerging face of healthcare demands successful transitions and positive post-discharge outcomes. By understanding the seven key drivers and implementing key best practices to address each, your organization will be best positioned to not only deliver a high quality of care, but also serve as the provider of choice in your community.

The other six drivers for successful patient transitions were: early and active patient engagement, identification of expectation gaps, in the moment patient feedback, patient education, patient readiness to self-manage and clear post-transition instructions.

Neil Gulsvig, CEO of Align, has more than 35 years of experience in the field of senior healthcare and extensive knowledge in human resources, communications and operations.

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