7 critical steps for physicians to help reduce readmissions

Internists and other primary care physicians can have a significant impact on reducing the risk of hospital readmissions, according to David C. Judge, MD, an internist and chief medical officer at Boston, Massachusetts-based Iora Health and a member of the Medical Economics editorial advisory board. He notes that the moment of a patient’s transition from an inpatient facility to home “is a particularly difficult moment” for patients and their families. In order to reduce readmissions, there are several steps physicians can take during this moment, including...

 7. Be aware as much as possible regarding the patient’s admission and plan for upcoming discharge.

The primary care team should make contact with the inpatient care team to get updated on the patient’s status and to be aware of the discharge plans.  The primary care team can often share information with the inpatient care team that is critical to the medical management such as medical history or recent evaluations that will influence decision making.  Some primary care organizations have the advantage of access to data that informs them on a daily basis regarding which of their patients are currently hospitalized.  Many primary care practices and teams nationally do not have timely information and must often rely upon patients, caregivers and families to keep them updated.

6.  Reach out to the patient within 48 hours of discharge.

The main goal is to discuss the areas outlined above and gain a deeper understanding of the patient and caregiver questions, concerns and their ability to manage the care plan.  This initial contact will often be done by a registered nurse but providers may need to be involved depending upon the complexity of the patient’s situation.  There are other care team members who are increasingly playing an important role in this communication including health coaches and medical assistants for example.

5.  Pay particular attention to performing a medication reconciliation process.

This is to clarify the medication list and dosing of all medications to be certain that the patient and caregivers understand medication management instructions and potential side effects of medications or signs that the treatment may not be effective.

 4. Work to assist the patient and caregiver in managing the scheduling of home services and specialty appointments.

3. Schedule the patient to be seen in the office as quickly as possible, but no later than one week from the date of discharge.

This is especially the case for patients who have been quite ill and have complex medical issues.  For patients who are very debilitated and cannot easily come to the office, consider a home visit if your organization can enable that to happen.

 2. Encourage and empower the patient and caregiver to reach out to the primary care team when additional concerns or questions arise.  

Scheduled phone check-ins can be incredibly reassuring to patients and caregivers.  However, reaching the team with unanticipated and urgent concerns by phone or email will be necessary and the team should do as much as possible to be certain that the patient and family understand how best to do that especially after usual office hours.

 1. Consider integrating the discipline of health coaching into your primary care team.  

Coaches are increasingly playing a critical role in the ways suggested above but also in working with patients to understand how they can increase their self-management skills and gain confidence in managing their health that will enable them to improve their health over time and reduce the risk of hospitalizations.