What Discharge Interventions are in Place to Reduce Hospitalizations?

Question

Answer

Discharge interventions are in place to reduce hospitalizations.

• Pre-Discharge
  • Education
  • Discharge planning
  • Medication reconciliation
  • Follow-up appointments
• Post-Discharge
  • Follow-up calls
  • Physician follow-up appointment
  • Home visits
  • Remote monitoring
• Bridging the Gap
  • Transition coaches
  • Discharge instructions
  • Continuity of care

Pre-discharge interventions include; patient and caregiver education, discharge planning, medication reconciliation, and scheduling follow-up appointments. This is completed by a collaborative team ranging from physicians, respiratory therapists, nurses, and social workers. A nursing team and social work conduct post-discharge phone calls. They are communicated with the ambulatory and DME providers, as well as set up for home care. Premature discharge or discharge to an environment that cannot meet the patient's medical needs may result in hospital readmission. Bridging the gap with a transition coach or a clinician can help reduce readmission rates and provide continuity of care.