Slide 41

Post-Discharge Activities

• Transmits discharge summary and Patient Care Plan to PCP
  • By fax: Ensures it is received and legible
  • By e-mail: Ensures it is received
• Makes follow-up phone call to patient
  • Uses script that includes medications and follow-up appointments
  • Determines need for second call by clinician

Notes:

“There are two main post-discharge activities. The first is contacting the patient's primary care physician. A communication breakdown between the hospital and the patient's primary care physician can increase the patient's chance for readmission or an emergency department visit. We are improving this transition of care by helping patients who do not have a primary care physician find one and then informing the primary care physician about the patient's stay with us. To ensure communication doesn't break down, we fax the discharge summary within 24 hours and also provide a copy of the Patient Care Plan to the primary care physician.

The second post-discharge activity is the follow-up phone call. Considering how quickly we send patients home, the first couple days after a hospital stay can be difficult for the patient. We call the patient between 48 and 72 hours after discharge to ask how things are going and if there are any questions about medications, follow-up appointments, and post-discharge services.”