Transitions of Care Challenges in Cardiology - Episode 9

Improving Transitions of Care to Reduce Readmissions

In order for hospital readmissions following discharge to be effectively reduced, explains Arthur Garson, Jr, MD, MPH, improvements must be made in many areas.

Dr Garson begins by suggesting that healthcare professionals identify the characteristics and overall needs of the patient prior to discharge. As an example, he highlights the University of Virginia’s TEACH questionnaire, which is used to categorize patients based on how they would like to receive their medical information. Dr Garson further explains that each patient needs to be assessed individually, because not all techniques work for all patients.

Additionally, Dr Garson discusses the role of the hospital discharge coordinator, and explains the importance of providing patients with written discharge instructions. Additional initiatives for reducing readmissions include following up with the patient in person or over the phone and recommending the use of various apps for mobile devices that remind patients to perform health-related tasks (eg, taking their medicine).

Dr Garson concludes by discussing the impact that fee-for-service payment models have on hospital readmissions and explaining how a transition toward bundled payments or capitation can help reduce readmission rates.