Shortfalls Among Best-of-the-Best
"It was surprising because many of these hospitals are part of large health systems, considered to be among the best-of-the-best, who signed up for this program," said Leslie Curry, a senior research scientist with Yale University and one of the authors of both studies.
The 10 recommended practices in the H2H program are
- Having a quality improvement team dedicated to reducing readmissions for heart failure and AMI patients
- Monitoring the percentage of patients with follow-up appointments within seven days of discharge
- Monitoring 30-day readmission rates
- Providing patients with medication management instructions
- Having a pharmacist available to patients for medication management questions upon discharge
- Having a pharmacy technician compile a patient's medication history
- Providing patients and caregivers with an emergency care plan
- Arranging a follow-up appointment for patients before they are discharged
- Alerting a patient's primary care physician within 48 hours of their discharge
- Contacting patients after discharge to answer any follow-up questions
Most of the shortfalls identified in the 2012 study were in the post-discharge area of care. The study found that only 22.9% of hospitals had partnered with local hospitals to manage patients at a high risk of readmission.