Medication adherence is a challenge for healthcare providers in the United States, especially during the transition from hospital to home. Poor adherence can lead to higher readmission rates, increased healthcare costs, and worse patient outcomes. About 20% of Medicare beneficiaries are readmitted within 30 days after discharge, and many of these cases are preventable. Issues often stem from poor communication, missed appointments, and misunderstandings about medications. To address this issue, providers should use effective strategies during postdischarge follow-up calls to ensure patients manage their medications properly.
Postdischarge follow-up calls play an important role in patient care. These calls typically occur 2 to 3 days after a patient leaves the hospital. They help providers check on the patient’s health, confirm understanding of discharge instructions, and address any issues that may arise at home. The Re-Engineered Discharge (RED) toolkit emphasizes the importance of these calls in improving patient safety and quality of care. Providers can ensure continuity in care by reviewing medication adherence, clarifying follow-up appointments, and coordinating home services.
During the follow-up call, it’s essential for healthcare providers to actively engage patients. This engagement can affect their understanding and adherence to post-discharge plans. The “teach-back” method is useful in confirming that patients understand their medications and treatment plans. Providers can ask patients to explain their discharge instructions in their own words to ensure clarity.
A challenge in post-discharge care is that about 20% of patients experience adverse events due to medication errors. Providers should use follow-up calls to review prescriptions and ask about any barriers to adherence. It’s important to address potential confusion about medication schedules, side effects, or logistical issues such as getting to the pharmacy. For instance, in one case from a Pennsylvania hospital, a follow-up call revealed a patient was not taking her diuretic because her bathroom was too far from her room. The hospital intervened by providing a commode, which helped prevent a readmission.
Medication adherence is significantly affected by social determinants of health, such as housing stability, financial resources, and transportation access. Providers who consider these factors during follow-up calls can provide better support. They can find out if patients have issues affording medications or accessing their pharmacy. This knowledge allows providers to tailor their recommendations and help bridge gaps in care.
To maximize the benefits of follow-up calls, healthcare providers should follow specific practices:
Communication between hospitals and primary care providers (PCPs) is often overlooked. After a follow-up call, it is important to relay any critical findings to the patient’s primary care provider. Effective communication helps ensure seamless care transitions, identify risks, and develop a comprehensive care plan. Using secure methods to update PCPs ensures everyone involved in the patient’s care is informed.
Technological advancements, particularly in artificial intelligence (AI), offer opportunities to enhance postdischarge follow-up processes. Companies like Simbo AI work on automating front-office operations, helping providers streamline tasks related to patient engagement. Here are some ways AI can improve follow-up calls:
Improving medication adherence for patients transitioning from hospital to home requires a comprehensive approach. By implementing effective practices during postdischarge follow-up calls, providers can engage patients and address medication issues to ensure continuous care. Incorporating AI technology and workflow automation can further support these efforts, leading to streamlined processes that benefit patients.
Providing quality follow-up care is essential. By focusing on patient engagement through effective follow-up practices, healthcare organizations can reduce readmission risks and promote a culture of patient care.
The postdischarge follow-up phone call aims to support patients from discharge until their first follow-up appointment by addressing their questions, confirming understanding of discharge plans, and ensuring continuity of care.
The follow-up call should be made 2 to 3 days after discharge to check the patient’s health status and adherence to the discharge plan.
A member of the clinical staff, preferably the discharge educator or a familiar team member, should conduct the follow-up call to maintain continuity of care.
During the follow-up call, assess health status, review medications, clarify follow-up appointments, coordinate home services, and discuss what to do if problems arise.
The ‘teach-back’ method can be employed where patients explain back the provided information in their own words to confirm understanding.
Prior to the call, review the patient’s discharge summary, after hospital care plan, and health history to tailor the communication effectively.
During the call, assess if patients understand their medication regimen and inquire about any barriers to adherence, including side effects or financial issues.
If a patient reports worsening health, an action plan may include patient education, contacting the healthcare team, or arranging a same-day appointment.
Document the follow-up call in the patient’s medical record, noting health status, medication issues, appointment status, and any follow-up actions taken.
Communicate with the primary care provider via secure email or other methods to relay any important information or discrepancies discovered during the call.
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