The post discharge process is a unique opportunity to create a trusting relationship between clinician and patient; raise the general health literacy of the patient; teach the patient how to safely manage his or her condition; improve clinical processes; and communicate the values of the institution to the patient and the patient’s community.
Here are some ground level recommendations:
1. It is important to know the impact your clinicians are having on the post discharge process:
- Script the post discharge conversation.
- Treat it as a clinical guideline in a checklist format.
- Train clinicians and non clinicians in communication skills.
- Create guidelines for each major condition.
- Track outcomes by guideline, clinician, and non-clinician.
- If using telephone follow-up, record all calls.
- Solicit and track patient feedback, concerns, and barriers.
- Implement grievance tracking and mitigation.
- Continuously improve based on tracking and feedback.
2. Post Discharge documentation is notorious for looking like an order sheet at a sandwich shop. This is an opportunity to market your hospital and educate your patients.
Put some thought into it:
- Have a third party review the clinical content and teaching opportunities.
- Have your marketing department create the discharge collateral.
- Have your patients review documents for clarity and completeness.
3. Deploy your vision and values within the post discharge process by demonstrating you care.
- Avoid statements such as “see your primary care physician within one week” - rather explain the patient’s role in briefing the PCP on their recent hospitalization.
- Have a script to identify patient barriers and how to overcome them:
- Follow up visits
- Medication regimens
- Meal preparation, etc..
- Deploy referral systems for services and physicians with secure email and traditional mail fulfillment capabilities – include your values on all communications.
4. Care coordination is critical.
Every patient has a care team, although members of that team may not be aware of one another or that they are even on a team. Accountability across the team and the patient, especially when the patient leaves the hospital, is amorphous at best. Managing the care coordination requires 24x7x365 availability.
Your organization or post discharge partner should have:
- Experience with practice call schedules and communicating with primary care physicians through a variety of messaging modes with time of day rules.
- 24 hour nurse triage for symptomatic and chronic patients with the ability to escalate in network care based on acuity.
- A post discharge checklist assessment system that generates real time alerts to PCP’s, hospitals and triage nurses when a patient is at risk.
- Intimate knowledge of the patient’s provider network and community services.
- An integrated system for assessing, triaging, and escalating patients to appropriate resources.
- The ability to communicate with any Electronic Medical Record.
5. Demonstrate you understand what drives the patient experience.
- Does the clinician (and the hospital) care? Are conversational pronouns personal and caring or institutional and directive? For example, “I have found this has worked well with my patients” versus “you need to do this...”
- Does the clinician appear knowledgeable about the patient’s condition? Can they communicate this knowledge in a simple and clear manner? Don’t leave it to chance - develop talking points – preferably narrations or “stories” around each major condition. Vary them over time.
- Is the clinician (and hospital) respectful the patient’s time? Know how much time the patient has been waiting for services — track it, improve it.
Post discharge management is a clinical process that utilizes a “patient checklist”. A checklist failure must be tightly integrated with on demand clinical resources, 24 hours a day. A “customer service” approach using only non-clinical agents will put the patient at risk. You will have “911” situations emerging from post discharge outreach.
In sum, success will be achieved by:
- Knowing the patient experience.
- Educating patients at each touch point.
- Measuring and refining clinical and clinician performance.
- Gauging the effectiveness of care coordination: does the system have depth, flexibility and intelligence?
- Communicating your institution’s values through words and deeds at every opportunity.
To a large degree, especially with the chronically ill, healthcare is longitudinal. Improving the quality of post discharge care can only strengthen the hospital network over time. Good news travels: Patients recommend good services to others, and will choose your services again when necessary.