Follow-up visits critical to prevent readmissions

Work with physician offices

Patients are at highest risk for readmissions during the first week after discharge, Donna Zazworsky, RN, MS, CCM, FAAN, points out.

That's why it's critical to make sure that patients have a follow-up visit with a primary care physician or a specialist within a week of being discharged from the hospital, adds Zazworsky, vice president of community health and continuum for Carondelet Health Network in Tucson, AZ.

"Case managers can do a wonderful job of educating patients, but if they don't get that follow-up visit, they are likely to have problems after discharge that could result in a rehospitalization or emergency room visit. The linkage to the community beyond the hospital walls is critical," she says.

Make sure patients have a follow-up visit before they leave the hospital and work with the patient and family to make sure they have transportation to get to the appointment, she adds.

Work with the clinics or physician offices in your area so they will give a discharged patient a priority office visit, rather than putting appointments off for several weeks, she says.

Identify the physician organizations that provide primary care for the majority of patients you discharge and invite their practice managers to the hospital for a meeting.

Keep in mind that physician office schedulers go by protocols when it comes to scheduling visits, but the practice managers can get your patients in for a visit if it's necessary, she says.

Zazworsky attends the monthly meetings of the practice management organization and works to make sure there are transitions in place.

"Case managers need personal contacts to make sure that patients get what they need after they leave the hospital," she says.

Patients who receive care from medical residents at the hospital clinics where there is a tremendous turnover and they don't see the same physician each time and those who have numerous doctors involved in their care are more likely to be readmitted, reports Elaine Keane, vice president for business development for Visiting Nurse Services of New York, a home care organization that collaborates with hospitals in the area on programs to reduce readmissions.

Hospital case managers can make sure that patients have a medical home and that their primary care physician and any specialists all have information on what happens during the hospital stay, she suggests.

Make sure the physician office understands that the patient needs to get in within three to five days of discharge.

The patient-centered medical home concept is gaining ground in many communities, Zazworsky points out. A major component of the model is care coordination for patients in the primary care setting, she adds.

Hospital case managers should find out which practices in their area are adopting the patient-centered medical home model and connect with the case managers in those practices to facilitate care for patients after discharge, she adds.