School of Medicine and Health Sciences Poster Presentations

Title

Reducing Readmissions through Patient Engagement Prior to Discharge

Document Type

Poster

Status

Medical Resident

Abstract Category

Quality Improvement

Keywords

hospital discharge, follow-up

Publication Date

Spring 2018

Abstract

Introduction: Hospital discharge follow-up with primary care providers is essential to ensuring patient safety between the inpatient and outpatient settings and in reducing readmissions to the hospital. Indeed, one in five patients suffers an adverse event during the first several weeks after hospital discharge and up to half of Medicare patients readmitted within 30 days were not seen in the outpatient setting after discharge. These findings highlight the importance of ensuring prompt primary care follow up. Two explanations for lack of follow-up are patients leaving the hospital without critical post-discharge appointments, or appointments that are scheduled do not align with patients’ schedules. Our project’s focus was to empower and facilitate patients scheduling their own appointments prior to hospital discharge.

Aim: Increase the proportion of patient-made follow-up appointments for patients admitted to the general medicine service from 0% to 50% by June 2018.

Methods: Patients were educated on the intervention and provided a checklist one to two days prior to the anticipated hospital discharge. The checklist described the rationale for the intervention, provided phone numbers to make appointments, and included a section for the patient to record appointment information. Patients who had appointments too important to be left to chance, who could not understand the intervention, refused to participate, or who were not being discharged to home were excluded from the intervention group.

Results: Three PDSA cycles were conducted focusing on improving the form layout, wording, and communication of the intervention. 41 patients were included in our analysis. 44% of patients met our entry criteria, and of these, 72% succeeded in scheduling their appointment with the use of the instructional checklist. Each PDSA cycle resulted in an increase in the number of patients who were successfully able to make follow-up appointments.

Conclusion: In this pilot study, we determined that for an appropriate subset of patients, a self-made post-discharge follow-up appointment is a viable alternative to current approaches and may result in improved transitions for care. While we did not meet our project’s aim, the rapid-cycle quality improvement process resulted in significant improvements in our targeted outcome. Our project’s future focus includes tracking appointment compliance and assessing patient outcomes such as re-hospitalization, adverse events, and patient/provider satisfaction.

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Reducing Readmissions through Patient Engagement Prior to Discharge

Introduction: Hospital discharge follow-up with primary care providers is essential to ensuring patient safety between the inpatient and outpatient settings and in reducing readmissions to the hospital. Indeed, one in five patients suffers an adverse event during the first several weeks after hospital discharge and up to half of Medicare patients readmitted within 30 days were not seen in the outpatient setting after discharge. These findings highlight the importance of ensuring prompt primary care follow up. Two explanations for lack of follow-up are patients leaving the hospital without critical post-discharge appointments, or appointments that are scheduled do not align with patients’ schedules. Our project’s focus was to empower and facilitate patients scheduling their own appointments prior to hospital discharge.

Aim: Increase the proportion of patient-made follow-up appointments for patients admitted to the general medicine service from 0% to 50% by June 2018.

Methods: Patients were educated on the intervention and provided a checklist one to two days prior to the anticipated hospital discharge. The checklist described the rationale for the intervention, provided phone numbers to make appointments, and included a section for the patient to record appointment information. Patients who had appointments too important to be left to chance, who could not understand the intervention, refused to participate, or who were not being discharged to home were excluded from the intervention group.

Results: Three PDSA cycles were conducted focusing on improving the form layout, wording, and communication of the intervention. 41 patients were included in our analysis. 44% of patients met our entry criteria, and of these, 72% succeeded in scheduling their appointment with the use of the instructional checklist. Each PDSA cycle resulted in an increase in the number of patients who were successfully able to make follow-up appointments.

Conclusion: In this pilot study, we determined that for an appropriate subset of patients, a self-made post-discharge follow-up appointment is a viable alternative to current approaches and may result in improved transitions for care. While we did not meet our project’s aim, the rapid-cycle quality improvement process resulted in significant improvements in our targeted outcome. Our project’s future focus includes tracking appointment compliance and assessing patient outcomes such as re-hospitalization, adverse events, and patient/provider satisfaction.