1. Perform an Enhanced Assessment of Post-Hospital Needs Before beginning improvement work, most teams believe that they are already performing enhanced assessments on admission. However, after completing the Diagnostic Review, teams gain new insights into what they are missing. Initial assessment should be completed upon admission, but ongoing assessment of home-going needs should occur throughout hospitalization. Early and ongoing assessment of needs after a a patient’s individualized care hospital discharge contributes to an individualized patient and family plan of care. Completing a comprehensive admission assessment requires additional time; roles and responsibilities need to be designated and standard work processes need to be developed. Typical failures in the assessment of discharge needs include the following: Excluding the patient and family caregivers in assessing needs, identifying resources, and planning for discharge, leading to poor understanding of the capacity to patient’s function in the home environment; Lack of probing around unrealistic patient and family optimism to manage at home; Lack of understanding of the functional ability, physical and cognitive health patient’s status, and social and financial concerns, which results in transfer to a care setting that does not meet the needs; patient’s Not addressing the whole patient (e.g., focusing on one condition, missing underlying depression, social needs, etc.);
1. Perform an Enhanced Assessment of Post-Hospital Needs Before beginning improvement work, most teams believe that they are already performing enhanced assessments on admission. However, after completing the Diagnostic Review, teams gain new insights into what they are missing. Initial assessment should be completed upon admission, but ongoing assessment of home-going needs should occur throughout hospitalization. Early and ongoing assessment of a patient’s individualized care needs after a hospital discharge contributes to an individualized patient and family plan of care. Completing a comprehensive admission assessment requires additional time; roles and responsibilities need to be designated and standard work processes need to be developed. Typical failures in the assessment of discharge needs include the following: Excluding the patient and family caregivers in assessing needs, identifying resources, and planning for discharge, leading to poor understanding of the patient’s capacity to function in the home environment; Lack of probing around unrealistic patient and family optimism to manage at home; Lack of understanding of the patient’s functional ability, physical and cognitive health status, and social and financial concerns, which results in transfer to a care setting that does not meet the patient’s needs; Not addressing the whole patient (e.g., focusing on one condition, missing underlying depression, social needs, etc.);
5%20-%20How-to-Guide%20Patient%20Assessment-Readmissions%20pgs%2016-21%20-%20Key%20Change%201.docx