Is it Okay to follow up with a Patient after They Leave the Hospital? The answer to this question may seem obvious to some, but in fact it can be far more complex than you imagine. The question really is not whether it’s OK to follow up with your patients, but more ‘when does following up become inappropriate intrusion’? Clinical studies have shown that patients who receive appropriate levels of follow up after discharge from hospital have far lower rates of readmission, and there can be little doubt about the clinical effectiveness of ensuring that your patients are equipped both mentally and physically to care for themselves in the community. It can also be reassuring and very helpful for their caregivers to know that they have not been forgotten, and that they have a point of contact for any concerns that they might have following their loved one’s discharge from the clinical environment. The Agency for Healthcare Research and Quality has an excellent ‘tool kit’ available on this particular subject. Known as RED (Re-Engineered Discharge), it explains the steps that help to ensure the best outcome for your patient and how appropriate follow up can help to avoid distressing readmissions further down the line and improve their health outcomes. Related: Why You Should Attend Nursing Events and Seminars What is RED? RED was designed by a team of researchers at Boston University Medical Centre. It consists of 12 ‘steps’ to help assist hospitals to reduce their readmission rates using useful and informative follow up with discharged patients. The program was designed over a period of 7 years and in conjunction with the National Heart, Lung and Blood Institute. Over this 7 year period, they carefully studied discharge procedures across multiple facilities, using methods that you would usually encounter in industries far removed from a healthcare setting, and that would probably be more familiar to those in corporate environments.
So, What Are The 12 Steps? 1. Does the patient require assistance with language or translation? After all, someone who does not understand their care or treatment plan is unlikely to be able to follow it. 2. Follow up appointments and care - does the patient have appropriate follow up appointments in place prior to their discharge? One of the major finding of the study was that patients who already have details of their follow up before they leave hospital are far more likely to attend and comply with the requirements of their program. 3. Ensure that a plan is in place to receive results from follow up tests, scans or labs testing that are required at the time of discharge. 4. If the patient requires access to outpatient services or equipment, ensure that both the outpatient department and the patient are aware of where they can be accessed and when. 5. Medication - make sure that the patient has a list of any medicines that are required for their treatment and that they have a plan on how and where to obtain them. 6. National guidelines - make sure that your patient’s discharge plan is accordance with any National Guidelines that are already in place. 7. Provide a written discharge plan, in a tone and language that the patient can understand. What seems straightforward to a health care professional can be bewildering and confusing for a lay person - having a written guide to refer to can help your patient as an aide memoir and provide much needed reassurance if they are unable to contact a healthcare professional with any concerns that they may have. 8. Education - talk to your patient about their diagnosis and medication. Make sure that they are fully aware of the function of any medicine that they are prescribed, and about any potential side effects. Ensure that they understand any physical limitations that they may encounter due to their diagnosis. 9. Ensure that your patient understands what to do if they run into difficulties or problems arise after their discharge. Talk about what can be
safely treated at home, and what might need medical assistance or emergency care. 10.Assess - do you believe that your patient understands their discharge plan? Do they need further assistance with language barriers or other barriers to understanding? 11.Expedite - ensure that the clinician accepting care of the patient postdischarge has a copy of their discharge summary, along with any concerns that you or the rest of the team may have about their ability to comply with it. 12.12- Provide appropriate telephone support to the patient following their discharge. Related: Balancing Nursing School with Your Life Although this sounds like a lot of work on paper, there are multiple reasons for making sure that all of your patients have access to post-discharge follow up. The study that this program was based on has identified a series of improvements that followed its implementation, including: Improves Clinical outcomes - by far the most important improvement, we know that this method reduces readmission by as much as 25%, and decreases inappropriate use of the ER by around 16%. Improved safety standards and documentation - not only does it document the discharge plan, it also documents the patient’s understanding of it. It’s accepted as NFQ safe practice, and also by many other patient safety bodies. Financial - On average, using RED reduces costs by around $412 per patient. Image - One of the results of the study showed that hospitals and healthcare facilities using the program benefited from improved community image, and both patient and caregiver satisfaction rose sharply.
What Does All of This Mean? In short, the answer has to be yes - appropriate follow up is nothing but beneficial to your patient’s well-being and also that of their families and caregivers. Carefully planned and documented follow up is a world away from occasional phone calls and ‘checking up’ on your patient - this is really all about empowering people who have recently been discharged and enabling them to take control of their own health care and medication. If you plan discharge appropriately, you may well find that constant ‘follow up’ is not required, as your patient will be well informed enough to contact you or another more health care professional if they feel that they are in need of support. This doesn’t mean that you have to forget about them as soon as they leave - in fact, it’s the opposite. If you have concerns about their ability to follow their care plan, it’s absolutely fine to contact them to see how they are doing and if they have any concerns, significant or otherwise. However, putting steps into place so that you follow the RED method will ensure that your calls and interventions are properly documented. It will provide reassurance for you, your team and your patient that your follow up is clinically appropriate, useful and required and give you a framework for any further assistance that your patient or his or her family may require. Best of all, you will have the benefit of knowing that this is a nationally recognized methodology that improves patient outcomes, has financial benefits for your institution and also helps to improve its image within the public and healthcare community. You really have nothing to lose by implementing all or some of the 12 steps when discharging patients from your care. Related: List of nursing organizations Please follow us on Facebook, Linkedin, Pinterest and Twitter