Post Discharge Programs Vital to Good Patient Outcomes

November 4, 2021 - by WELL Staff

When a patient is released from a hospital stay, the hope is that their medical issues have stabilized enough that they can continue their road to recovery at home and any needed post discharge follow-up is underway. However, a study published by the National Center for Biotechnology Information states that the reality is 10.3% of hospital discharges result in a readmission. While some readmissions cannot be avoided, a UC San Francisco study found that approximately one-quarter of hospital readmissions are preventable.  

Hospital readmissions cost Medicare $26 billion annually. Not only is this problematic for patient outcomes, but readmissions also take a toll on providers’ already-strained finances. Through the CMS Hospital Readmissions Reduction Program (HRRP), hospitals are now penalized if they exceed the median readmissions performance of their cohort. Medicare recently released data showing the latest payment adjustments to hospitals under the HRRP, reporting 83% of hospitals will face penalties for the fiscal year 2021.

Studies show patients are unclear about post discharge instructions

As hospitals strive to shorten the patient’s length of stay, more effort is needed to ensure that the patient and their caregivers have an adequate understanding of post discharge plans to reinforce key care concepts during the transition home. A seminal 2005 Mayo Clinic study found that “less than half of … study patients were able to list their diagnoses, the name(s) of their medication(s), their purpose, or the major side effect(s).” The researchers concluded that “lacking awareness of these factors affects a patient’s ability to comply fully with discharge treatment plans.” 

Other studies have identified similar gaps. For example, a 2012 Columbia University Medical Center study on post discharge instruction understanding among patients with heart failure found that only 10% of 145 patients fully understood all six of The Joint Commission’s recommended topics for heart failure management. 

Research indicates post-discharge communication is key to patient understanding of instructions

The Agency for Healthcare Research and Quality (AHRQ) worked with researchers at the Boston University Medical Center (BUMC) to develop the Re-Engineered Discharge (RED) toolkit, a set of resources to help hospitals implement improvements to the discharge process. The goal of RED is to prepare patients and their families for leaving the hospital, improve their satisfaction with the process, and decrease hospital readmission rates. According to RED, patients should be called post discharge in order to clarify the patient’s next steps, provide an opportunity to ask questions, and address any discrepancies in their discharge plan.  

Creating open lines of communication with patients can also help avoid unnecessary ED visits. A study of 1000 general medicine patients readmitted within 30 days of discharge found multicomponent care transitions programs help improve patient outcomes in the period after acute care. Investing in patient education, post discharge monitoring, medication safety, and promoting self-management are all factors that can help to reduce hospital readmissions. Along with self-management, educating patients on who to contact and when to go (or not go) to the emergency department is key to preventing readmissions.  

Digital technology enables patients and providers to connect post discharge

 A key factor to address when implementing post discharge programs is that self-management can be challenging for patients and their families due to the amount of information that they need to absorb. Using technology for distributing discharge instructions and establishing an open channel of two-way patient communication between patients and providers makes it easier for patients to get the help they need when they have questions after leaving the hospital. Discharge instructions given to the patient on paper can easily be lost, but digital instructions are accessible through smartphones and computers. Digital communication tools have an important role to play in the event the patient has questions about their instructions or their medication, or if the doctor needs to check in with the patient.

For example, researchers at the Medical University of South Carolina have been experimenting with digital medication reminder messages to kidney transplant patients who often need to take around 15 medications a day. These messages not only serve as a medication reminder to the transplant patients, but they also help the patients to stay adherent to their treatment plans. 

Bidirectional texting and AI technologies enable effective post discharge communication

Another consideration for adopting digital health solutions is that healthcare providers are extremely short-staffed and depending, on the size of the organization, many are not able to make and complete post-discharge calls as recommended by RED, especially since sometimes it takes multiple attempts before a patient can be reached. 

Technology, such as bidirectional texting, can be used to facilitate patient/provider communications without placing additional burdens on the medical staff. More sophisticated technology such as AI-enabled conversations using ChatAssist AI, a new functionality from WELL, can communicate information to patients and handle common questions with the ability to automatically escalate to staff members if the patient has more complex needs. 

Customize messaging to the needs of your patient population

An important factor to keep in mind in post discharge messaging is the patient’s primary language and education level. WELL offers multiple language options and has the ability to send links to educational content such as videos to ensure that patients can understand post discharge instructions even if English is not their first language. 

For many patients, receiving a lengthy printout of instructions while in the hospital can feel overwhelming and hard to interpret. Instead, short, conversational text messages about their treatment program, such as check-ins on their level of pain or if they are taking their medications, can be more digestible for patients. The health system’s ability to customize patient communication will help facilitate a successful patient/provider relationship and increase the level of patient engagement. 

Digital healthcare communication tools deliver value

As value-based health care policies grow in importance, the need for better post discharge communication is evident. In order for discharge plans to be effective, the patient needs to understand their instructions and have the ability to communicate with their doctors. Digital healthcare communication tools are key to driving better outcomes through a comprehensive post discharge program.♥

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