REFERRAL AND FOLLOW-UP Coordination and Planning for Follow-Up Appointments The absence of follow through on the discharge plan has been found to be a reason for rehospitalizations. Patients frequently don’t understand the discharge plan or the importance of all instructions, and often believe they can’t follow it. The emphasis of quality improvement efforts has been to remove sole responsibility for referral and follow-up from the patient to the system. This involves efforts to educate and motivate the patient about the importance of the discharge plan in their recovery. It also includes contact with system personnel to ensure the discharge plan is followed or changed, if necessary. The development of a transitional care plan (“discharge plan”) is a crucial element in the coordination and planning of services post-discharge. The design of a transitional care plan should include all components necessary for the patient, family and caregivers to understand and follow through with the instructions. Clinical experience with the transition process has identified common failures that may occur during this stage. Stratis Health of Wisconsin’s Reducing Avoidable Readmissions Effectively (RARE) Campaign has noted these issues and established strategies clinicians can implement to develop transitional care plans that are complete, easy to understand and realistically achievable. 6. RARE Typical Transition Best Practices/Strategies for Improvement Proposed Process or Outcome Failures Measures No follow-up Assess the patient's understanding of the Next clinic appointment is appointment discharge plan by asking them to explain in their made and documented scheduled, or own words Discharge instructions appointment Assign accountability for patient issues include warning signs and needed with between hospitalization and next provider visit and symptoms additional provider inform the patient of who is in charge of their care Discharge instructions expertise and how to contact them include who to call if Follow-up with Give the patient his/her patient health record experiencing warning and provider too long that includes patient diagnosis, test results, symptoms hospitalization
REFERRAL AND FOLLOW-UP Coordination and Planning for Follow-Up Appointments The absence of follow through on the discharge plan has been found to be a reason for rehospitalizations. Patients frequently don’t understand the discharge plan or the importance of all instructions, and often believe they can’t follow it. The emphasis of quality improvement efforts has been to remove sole responsibility for referral and follow-up from the patient to the system. This involves efforts to educate and motivate the patient about the importance of the discharge plan in their recovery. It also includes contact with system personnel to ensure the discharge plan is followed or changed, if necessary. The development of a transitional care plan (“discharge plan”) is a crucial element in the coordination and planning of services post-discharge. The design of a transitional care plan should include all components necessary for the patient, family and caregivers to understand and follow through with the instructions. Clinical experience with the transition process has identified common failures that may occur during this stage. Stratis Health of Wisconsin’s Reducing Avoidable Readmissions Effectively (RARE) Campaign has noted these issues and established strategies clinicians can implement to develop transitional care plans that are complete, easy to understand and realistically achievable. 6. RARE Typical Transition Failures Best Practices/Strategies for Improvement Proposed Process or Outcome Measures No follow-up appointment scheduled, or appointment needed with additional provider expertise Follow-up with provider too long hospitalization Assess the patient's understanding of the discharge plan by asking them to explain in their own words Assign accountability for patient issues between hospitalization and next provider visit and inform the patient of who is in charge of their care and how to contact them Give the patient his/her patient health record that includes patient diagnosis, test results, Next clinic appointment is made and documented Discharge instructions include warning signs and symptoms Discharge instructions include who to call if experiencing warning and symptoms
Behavioral%20Health%20Care%20Toolkit.docx