Discharge planning has been making headlines recently because of Medicare's hospital readmission and reduction program.
Hospital readmission rates are coming under scrutiny not only by Medicare but also commercial payers and consumers alike, in an effort to manage the high cost of readmission after patient discharge. Successful discharge planning keeps the rate of readmission low.
For patient advocates, successful discharge has always been part of our mission. Patient advocates strive to coordinate care and ensure a smooth transition from hospital to home.
There are many variables that contribute the whether the patient will have a successful transition. For example, very often the patient will go into the hospital on medications and leave with new ones. When they get home, are the new meds implemented or do they continue to take the meds they have at home, the ones they took prior to admission? Patient advocates work with the client to make sure they understand the medications and ensure medication management.
Other transitional issues are patient education and continuity of care. During the discharge process the patient needs to be clearly educated about their illness, prognosis and post-discharge instructions. This is especially important for those with chronic conditions; simply handing the patient discharge papers does not work. Patient advocates excel at facilitating communication and care coordination across the medical continuum.
Many patients have several co-morbidities, yet doctors rarely communicate with each other. It's the job of the patient advocate to ensure all the physicians are talking to each other and are all on the same page regarding the patient's diagnosis and prognosis. In addition, if the hospital employs hospitalists, the patient's information needs to be clearly communicated to their regular physician or the new provider.
Patient advocates also schedule and accompany the patient to follow-up care and, if necessary, arrange transportation. Patient advocates make certain the patient understands the doctor's instructions and has the ability and the resources to implement the orders.
Numerous patients will need home healthcare or rehabilitation after hospitalization. A patient's quality of life can be directly impacted by the kind of therapy and rehabilitation they receive after discharge. Getting the patient placed in the appropriate facility is paramount to successful recovery. I cannot stress this enough, as all too often the discharge manager needs the bed and the patient is placed at the first facility that will accept them. If a patient belongs in an acute rehab facility, they should not be placed in the sub-acute up the street.
Patient advocates have the resources to direct their clients to the appropriate facility. They also place and oversee home health care agencies, ensuring the patient's care and personal needs are met. Additionally patient advocates guide the patient to available resources in the community, be it support groups, mall walkers or needed professional services.
Overall, patient advocates guide the patient through the medical system and provide care management each step of the way. Yet hospitals are very slow to engage or even refer to patient advocates. Most patient advocates work in private practice, retained by overwhelmed family members or the patient themselves. With the escalating cost of hospital care, coming readmission penalties or simply for the sake of the patient, getting on board with patient advocates or contracting with independent certified patient advocates is a sure way to save the hospital money, ensure patient care coordination and lead to better outcomes.
Believe me, there is nothing more frustrating or overwhelming to the patient and the family than the vicious cycle of hospitalization, rehabilitation and home only to end up back in the hospital, starting the process all over again. Let's try to get it right the first time.