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Post Discharge Follow Up Improve the Patient Experience

Why You're Failing to Manage Care Transitions After Discharge (and How to Fix It)

Why You're Failing to Manage Care Transitions After Discharge (and How to Fix It)As we discussed in the previous article, The Future of Patient Experience Management, following up with patients after they leave the hospital is critical to finding issues that impact patient health and their experience of care—and the telephone remains the most effective way to connect with patients after discharge.

The rates at which you’re able to conduct follow-up calls, connect with patients, and glean relevant data continue to be stubborn obstacles for organizations of every size.

However, what many organizations fail to realize is that their biggest challenge revolves around change management—the act of shifting calling schedules, script messaging, feedback notifications, and reporting.

The Post Discharge Follow Up Process at a Glance

Before we dive into the capabilities required for an effective change management process, let's take a closer look at what needs to happen during the post discharge follow up process.

Generally speaking, there are some steps that must occur in order for you to ensure each patient's unique transition out of the hospital is successful and that you're able to capture the experience information you need to drive improvement initiatives. 

Step#1 Connect with the patient

Follow up programs that connect with patients quickly after discharge, and can coordinate next steps, are extremely effective in identifying and filling any gaps in care that can lead to poor healthcare outcomes.  

Keep in mind that your post discharge follow up calls need to build on the trust your hospital staff has already created. This means having compassionate individuals make the calls, asking relevant questions, and being able to resolve any issues, clinical or otherwise, quickly.

Step#2 Determine health status and escalate appropriately

As you make post discharge follow up calls, you will encounter patients experiencing health issues. For patients experiencing acute symptoms, this means providing them with clinical decision support (e.g. nurse triage) in order to identify what the appropriate next course of action is.

If the person conducting the follow up call isn’t a clinician, there needs to be a process in place that can escalate them to a licensed professional (like a registered nurse) right away.

Step#3 Determine comprehension of post discharge care instructions

Patient compliance with post discharge care instructions is one of the biggest challenges healthcare providers face when managing patient care transitions. Not only does instruction non-compliance put patient health at risk, it can significantly impact the perception they have of their hospital experience.

As you look to improve the services you provide compared to other hospitalsand past performanceyou need a way to continuously monitor how well your patients understand their discharge instructions.

Step#4 Remove any barriers to appropriate care compliance

In addition to helping patients understand their discharge instructions (and connecting them to a triage nurse when needed), your goal should be to resolve any and all barriers to recovery identified during the follow up call as quickly as possible. This means coordinating a variety of other relevant healthcare resources.

Depending on the needs of the patient, this can include (but is not limited to) providing referrals to PCPs and/or specialists, scheduling appointments, Rx assistance, or any number of other healthcare activities.

Step#5 Capture patient experience feedback

As you progress through the post discharge follow up process you will, without a doubt, gleam important details about the patient's experience of care. But to make sure you are capturing all the information you need to identify processes and/or people that substantially impact the patient experience, you need to ask very specific questions about the healthcare service they received. 

Step#6 Compile and report patient health and experience data

Having a clear picture of what causes patients to feel they had a poor experience allows you to prioritize where to make improvements within your operations. This means having a way to track, trend, and report on the data you capture during the post discharge follow up process.

In order to make significant gains on patient satisfaction, you need to pay regular attention to your reports and program analytics—keeping in mind that as your program evolves, so will your reporting requirements.

The Secret to Post-Visit Follow Up Is Using the Right System

As you can see, following up with patients after discharge isn’t just about asking questions. It’s about providing support in a way that is meaningfully customized for each patient.

In other words, the timing, interaction, and follow up activities of your post discharge discharge follow up process—all of which are required to provide appropriate care and gather relevant feedbackwill vary significantly from patient to patient. Moreover, as operational improvement priorities change within your organization, the experience data you set out to capture (and report on) will continuously change as well. 

To accomplish this, you need to utilize a rules-based system that has the following capabilities:

    • Variable Call Scheduling—Every patient is different and needs to be contacted on a schedule relevant to their specific follow-up care needs. While 24 hours is a good benchmark, the reality is timing and frequency will change based on a variety factors.
    • Patient Interaction Scripts—The right scripting solution ensures your post discharge follow up team provides consistent, personally relevant interactions and guidance to patients while still being flexible enough to change questions, messaging, escalation rules, and notification triggers based on the patient experience activities and goals important to your organization.
    • Closed-Loop Feedback Notifications—While your ability to effectively connect with patients and capture relevant data are fundamental components of your post discharge follow up process, the real power of your program resides in its ability to send departments and/or employees service issue notifications so that they can take action.
    • Dynamic Reporting—The right analytics provide you with valuable insight into the impact you’re having on patient outcomes and help determine which tactics are working—or not working —for your recently discharged patients. Without the ability to measure program performance, you can’t improve patient safety or satisfaction. 

The Evolving Nature of Patient Experience Improvement

As you identify and solve patient experience issues, the goals of your program will shift to address new opportunities for improvement. This is because the only way to significantly improve the quality of care you provide (and the perception patients have of that care) is to methodically identify and fix areas of your service that negatively impact patient care.

Continuous process improvement must become part of your operational DNA, where every employee is held accountable for how they impact satisfaction and how they fix any service issues that are discovered.

Without this commitment to improvement—and the ability to coordinate process changes quickly—you will be unable to take advantage of the information you uncover during follow up, reducing your ability to impact your patients experience of care.


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