A recent report from the American Medical Association (AMA) highlights the critical role office-based doctors play in helping their patients make safe transitions after being discharged from the hospital.
To help avoid rehospitalizations, physician practices should:
- Keep organized information on patients’ medical issues, health goals, functional and psychological status, and behavioral and social issues.
- Consider patients’ acute, intermediate and long-term care goals.
- Be explicit with patients about social, economic, cultural and other factors that may impede their care.
- Use reader-friendly tools such as checklists and “red flag” lists to help patients and caregivers with self-management tasks.
- Use motivational interviewing and teach-to-goal methods to support self-care.
- Use pharmacy, patient and hospital discharge lists to ensure a fully reconciled and accurate medication list after discharge.
- Reinforce medication changes made in the hospital with patients, as appropriate.
- Use “pill cards” to help patients track drug changes.
- Allocate time to address care coordination tasks, using templates and checklists for specific tasks.