ExperiaHealth recently hosted a webinar featuring Dr. Michael Palumbo,Medical Director and Executive Vice President at White Plains Hospital; Dr. Michael R. Goldner, Associate Chief of Staff at Lehigh Valley Hospital Muhlenberg; and Sandra Thompson, Director of Quality Resources / Corporate Compliance Officer, at Laurens County Health Care System.
These thought leadersdiscussed their organizations’ best practices to reduce readmissions and improve patient experience. While each hospital is unique in size and patient population, they share these five proven strategies:
Patient Risk Stratification:
Identifying high-risk patients early is essential to reducing readmissions, according to all three experts. Each hospital assesses patient risk at admission using customized analysis tools tailored to the organizations’ patient populations.The risk stratification tools capture medical data as well as social and behavioral attributes such as health literacy, patient transportation barriers, access to skilled nursing facilities, and whether a patient lives alone or has a strong support system outside the hospital.
Risk stratification continues with care rounding, which helps identify and close gaps in patient communication and experience. Rounding can be performed by a single care team member or by a multi-disciplinary team that includes a physician, nurse, dietician, pharmacist and/or another member of the clinical or support staff. Regardless of the approach, rounding allows for patient needs to be addressed quickly, which improves patient engagement, satisfaction and outcomes.
Recorded Discharge Instructions:
Patient and family engagement plays a vital role in experience and outcomes. To improve engagement, the hospitals have implemented the Good to Go® solution by ExperiaHealth, which allows the care team to record live discharge instructions at the patient bedside. The instructions are available to the patient, family, and other caregivers to review at anytime using any phone, computer or mobile device. The solution hardwires best practices such as teach-back and spaced repetition into the discharge process, bridges gaps in health literacy, and empowers patients and families during and after a hospital stay.
Post-Discharge Follow-up Calls:
Our panelists agreed that follow-up calls to high-risk patients after a hospital stay improved experience and helps close clinical gaps before they escalate to readmission. During post-discharge calls, hospital staff members gauge patient engagement, understanding, and compliance of the care plan and may include an overview of discharge instructions, confirmation of follow-up appointments, and medication reconciliation. Follow-up calls also allow care team members to make inquiries about any social and behavioral challenges that were identified during the risk stratification analysis and to initiate interventions as needed.
Engaging community healthcare partners such as skilled nursing facilities (SNF) also makes a positive impact on patient safety, experience, and readmissions rates. These three hospitals partner with and extend communication to SNFs to ensure a seamless patient transition. By providing SNFs with access to patient risk information and discharge instructions, these skilled nursing caregivers know exactly what the patient was told, what potentials issues could arise, and the next steps required to care for the patient. If the connection between the hospital and SNF is strong, any readmissions that do occur can be reviewed to identify trends and design improvements.
There are many hospital executives, doctors, nurses, and other healthcare professionals who are leading change and implementing innovative solutions to improve and humanize healthcare. We salute these pioneers and offer a national platform for them to share their expertise, experience, and strategies to help others improve patient loyalty and create lasting differentiation.