Aftercare Success

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Better post-discharge follow-up creates a win-win for providers and patients alike.

Story: Joy Stephenson-Laws

A recent study by Boston University School of Medicine reinforces how discharge planning can reduce readmission rates while increasing patient health and satisfaction. It also clearly demonstrates the importance of ongoing physician involvement in aftercare in ensuring the success of discharge plans.

In the usual process, a physician develops the discharge plans but doesn’t make a home visit or continue to actively monitor a patient after discharge. 

But in this particular study, researchers found when resident physicians visit the homes of former hospital patients, they can better assess patient needs and understand the role community services and agencies play in keeping patients out of the hospital. A key element of the follow-up is a review of the original discharge plan to determine how effective it is.

The major takeaway from this study was improved assessment of patient needs and development of more personalized discharge plans, including medication reconciliation and caregiver communications, which are keys to successful transitions. While this study focused on older adults, the approach could be used to improve services for younger patients.

Another study, reported by the National Institutes of Health, suggested better discharge-planning quality is associated with lower rates of hospital readmissions for patients treated for heart failure, pneumonia, and partial or total hip replacement.

There are two key challenges for enhancing discharge planning follow-up. One is operational and the other, as expected, is financial. Many providers cannot devote staff time to data collection, training, and other logistical management required to ensure a successful discharge. On the financial side, there is still some uncertainty about the exact return-on-investment of more comprehensive follow-up on discharge plans. Anecdotal evidence, however, suggests that they do result in a net cost saving.

Another important element to consider is that discharge planning should be viewed as a key element of the continuum of care. This type of approach tends to be more interdisciplinary with an integrated team of primary care physicians, hospitalists, pharmacists, physical therapists, community-based organizations, and the patient’s personal caregivers. 

Remember, there is no such thing as a one-size-fits-all approach to post-discharge planning. Providers can, and should, develop approaches for the most effective—both in terms of cost and outcome—plans for their unique needs and patient population.

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Here are some steps providers can take to enhance post-discharge planning:

Get creative.
Tailor the discharge instructions to fit the needs of individual patients and limit “medical speak.” One provider in West Virginia, for example, realized some older patients couldn’t read scales, which is important for heart-failure patients to monitor fluid retention. The solution? Patients were told to try on their best shoes every morning. If the shoes fit, they were doing well. If they didn’t, patients likely were retaining fluid and needed to call their doctor.

Involve caregivers.
The Caregiver Advise, Record and Enable Act, enacted in a majority of states, requires providers to involve caregivers and family members in discharge planning. Complying with this law pays dividends as evidenced by some providers reporting up to a 25 percent reduction in the risk of older patients being readmitted.

Make medication a focus and not an adjunct.
More than half of medication errors affecting more than 1.5 million people occur during care transition. Reports say almost half of all patients have a clinically significant medication error within a month of discharge. Clearly, patients and caregivers must be properly educated about medications given upon discharge.

Tap volunteer and community support.
Most providers have a community volunteer corps that helps with operational tasks. Consider expanding that network to conducting follow-up with patients after discharge or creating a post-discharge call center.  

Pilot a variety of approaches.
Academic institutions and health-care organizations offer a wide variety of discharge planning tools and models. Study these resources to identify what might work. Once identified, initiate a pilot program to customize the plan.  

Look beyond medical issues.
Other issues include transportation to a doctor or pharmacy, safe housing, and community resources for social and other needs.

Adequately account for the cost of proper discharge services in the chargemaster.
Include the added costs associated with enhanced discharge planning in the total price charged for medical services. The chargemaster is generally where the official rates for the various procedures and services from the hospital is located. It is also the basis for receiving payment from governmental and commercial payors.


To be successful, post-discharge planning and patient education must go beyond a routine, cursory meeting at discharge. By taking a more wholistic, integrated, and transitional approach to this critical element of hospital care, providers create a true victory for themselves, patients, and their communities. 


About the writer:  Joy Stephenson-Laws is founding and managing partner of Stephenson, Acquisto, and Colman, a leader in health-care reimbursement law.

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