For example, Neuwirth says "teach back," a process by which patients are asked to verbally repeat their discharge plan instructions, was one important change in procedure that resulted from the video experience.
"And we realized that a lot of patients, particularly those with chronic conditions like congestive heart failure, need referrals to a dietician once they go home, so they can understand what we mean when we ask them to limit salt or fluid intake. We weren't always fully leveraging those resources," she says. “By talking with patients and observing how they live we came to better understand what they need and how we as a system could better wrap our arms around those needs.”
Lastly, they realized that many patients had unrealized psychiatric and social support issues. They said they found five major categories of missed opportunities that may have contributed to readmissions, the biggest of which dealt with clinical care. For example, for nearly 120 of those 600 discharged patients the medical condition was not optimally managed or monitored closely enough.
They found other major categories of missed opportunities, such as the need to need to improve home transition planning and care coordination, follow up care, end of life explanations, advance directive care as well as medication management.
Patients told them, for example, that they "did not know how to reach their doctors, saying "I don't even know who to call about this pain," or that when they were discharged, they were given 10 phone numbers to call.