Hospitals that are doing the best in avoiding major penalties for readmissions are providing post-discharge visits to reinforce teaching, review medication, and make sure patients have a follow-up appointment and keep the appointment, says Wanda Pell, MHA, BSN, a director with Novia Strategies, a national healthcare consulting firm.

“I’m seeing a real increase in home visits and house calls to follow up with at-risk patients. A lot of hospitals send someone to the home at least once to check on the patients and their home environment,” she says.

Going into the home is a good way to identify any problems such as lack of food in the refrigerator, or safety issues such as throw rugs and electrical cords snaking across the room, adds Teresa Marshall, RN, MS, CCM, senior managing consultant for Berkeley Research Group.

“The nurse can examine all of the medication in the home to make sure patients aren’t taking duplicate drugs or something that interacts with the medication prescribed,” she says.

Patients feel more comfortable in their own environment than in the hospital and are more likely to absorb the education and ask questions, she adds.

Marshall recommends having a home care nurse visit high-risk patients a day after discharge. “Just one visit can make a huge difference,” she adds.

Many patients who are readmitted have not had a follow-up visit with their primary care provider, Pell says.

“It takes an average of 19 days to get an appointment with a primary care physician. That’s more than halfway through the 30-day period in which hospitals are penalized for readmissions,” she adds.

Hospitals have had mixed results with making appointments for all patients at discharge, Pell says. If a clinical person calls to make the appointment, they often can get an appointment sooner than if the patient calls. On the other hand, if the patient has to rely on others for transportation, the appointment may not fit into their schedule.

It’s important to empower patients and/or caregivers to own and understand the disease process, Marshall says. “They need to know how to identify risks early and contact their providers to intervene before it becomes a serious problem. The education should begin in the hospital but continue after discharge,” she says.

Pell advises case managers to provide follow-up telephone calls to reinforce what patients heard in the hospital.

“Despite the best efforts of the inpatient staff, patients and family members don’t recall a lot of what they hear on the final day of hospitalization and many never read any of their discharge education,” Pell adds.

Some hospitals have pharmacists make the follow-up phone calls to patients, Pell adds. “Since the majority of questions patients have after they get home are around medication reconciliation, having someone who understands the medication regimen and can walk them through it is very effective,” she says.

The follow-up phone calls should include probing questions that require more than a “yes” or “no” answer, Marshall says.

For instance, the person who makes the calls after discharge should go further than just asking patients if they got their prescriptions filled. Ask them what pharmacy they used, what medication they got, and how they are taking it, Marshall advises. If you still have questions, call the home care agency and have them make a visit to check on the medication.

If patients have problems, reach out to the case managers in the primary care physician office and ask them to facilitate an appointment as soon as possible before the problem gets worse.