After hospital discharge, people are often sent home with a vague idea of what to do next, such as scheduling a follow-up. This lack of coordination can confuse patients, leaving them unsure where to turn.
Unfortunately, that may lead people to abandon treatment, avoid follow-ups, or miss signs of infection—which could result in readmission.
However, PCPs can help fix this problem. By using a variety of strategies, primary care doctors can keep patients healthier and play a role in reducing hospital readmissions.
Readmission Reduction Strategies
When PCPs can identify issues post-discharge, like medication errors or infections, it helps reduce readmission rates.
That said, hospitals and primary care providers must work together to determine how to reduce hospital readmissions. To get the ball rolling, here are some strategies PCPs can consider implementing:
Post-discharge Communication
Primary care physicians should be in close contact with the patient, ideally upon admission. However, it’s especially crucial to follow up with them after they leave the hospital.
Your team should promptly conduct post-discharge phone calls and follow-ups. By doing so, you can address challenges quickly and provide the information a patient needs to stick to the post-discharge plan.
Here are some topics PCPs should discuss with these individuals:
- Medication reconciliation
- Follow-up visits at the primary care office or with specialists
- Accurate contact information
- Barriers to health
- Potential complications
- Review of post-discharge instructions
Ideally, hospital providers will have already covered this information with the patient. However, reviewing it again can reinforce the discharge plan, clarify areas of concern, and help you flag high-risk patients.
Care Coordination
Coordinating with hospitals is an important task that, when overlooked, can cause communication errors and care delays. One model of post-discharge care coordination comes from the Agency for Healthcare Research and Quality (AHRQ). The five principles are:
- Primary Care Integration: People leaving the hospital should turn to their primary care office for continued support. Staff should collaborate with the inpatient team to facilitate the patient’s transition back to your office.
- Differentiated Follow-Up Visit: Primary care providers will need to allot more time to recently discharged patients. The first follow-up after an inpatient stay should be with the PCP.
- Team-Based Care Definition: Your office should assign specific responsibilities to clinical and nonclinical team members. Ensure a timely review of these roles to streamline the transition process.
- Systematic Approach to Care Coordination: Set up systems to notify you of your patients’ admissions and discharges. Additionally, work with hospital-based teams to assist with discharge planning and other consultations.
- Whole-Person Needs: PCPs should be able to identify care priorities, risk factors, and barriers that may interfere with a patient’s treatment. For example, you’ll need to examine their medical literacy, behavioral health, and social needs.
For ideas on incorporating these principles into your practice, try the AHRQ guide’s suggested workflow.
Social Determinants of Health (SDOH) Screenings
One of the factors that has come up in previous strategies is health barriers, many of which are part of the SDOH. These situations influence a patient’s ability to follow treatment advice or attend appointments.
As the PCP, you should regularly screen patients for these concerns:
- Food insecurity
- Housing instability
- Unemployment
- Childcare options
- Transportation concerns
- Education levels
- Healthcare access
Identifying these issues makes it easier to connect patients to housing, childcare, and food assistance. Additionally, understanding SDOH helps you address factors that could hinder health outcomes.
Tools to Reduce Hospital Readmissions
PCPs can also implement a variety of tools to reduce the likelihood of hospital readmissions. Examples of tools you may find helpful include:
- Remote monitoring devices: These devices monitor patient metrics after discharge. With early detection, you can provide guidance and schedule follow-ups before a problem escalates.
- Questionnaires: A simple way to gain a basic understanding of the SDOH affecting your patients is to have them fill out a questionnaire. Then, you can use this information to connect them to the appropriate resources.
- Telehealth: In some cases, you can opt for a telemedicine follow-up visit. These visits make it easier to check in without needing patients to miss work, find childcare, or get a ride.
- Artificial intelligence (AI): AI is here to stay. While it can’t (and shouldn’t) do everything, it can be a beneficial tool for PCPs. For example, automated point-of-care decision tools can help identify people at high risk of readmission, allowing you to be proactive.
Hospitals may also use the RED Toolkit, a 12-component action list for discharge planning. Although hospitals take the lead with the toolkit, PCPs play a role in the process, so being aware of its contents could be beneficial.
Importance of Reducing Readmission Rates
Readmission is a significant concern for both patients and providers. Although some readmissions are unavoidable, there are benefits to reducing them overall:
- Improved patient outcomes
- Lowered healthcare costs
- Increased patient satisfaction
- Higher indication of high-quality care
Additionally, reducing readmission rates can also decrease health disparities. Many readmitted patients come from underserved groups, including minorities, people with disabilities, LGBT+ individuals, and those living in rural locations.
Curious about how your practice can help reduce hospital readmission rates and provide quality care? Get started by checking out our upcoming continuing medical education (CME) conferences.
