Donnelly agrees that the key to keeping patients from being readmitted to UPMC Hamot is staying in contact with after-care facilities.
"We don't run a number of the clinics [that we refer patients to] … but we've created strong affiliations with them and work with them to collaboratively make that a success," he says.
Turning a bystander into an engaged patient
UPMC Hamot, Lancaster General, and IU Health Ball Memorial have found that following up with patients and their caregivers immediately after discharge often helps keep patients from being readmitted.
IU Health Ball Memorial uses the traffic light technique to teach patients how to categorize their health and progress.
Green means they are on target, yellow means there is cause for concern, and red means the patient's condition has worsened. For example, if a patient's weight is on target and he is feeling well, he learns to categorize that as in the green zone. But if the patient has suddenly gained weight and is feeling fatigued, he would describe that as the yellow or red zone.
Providers begin using the traffic light technique with the patients while they are in the hospital and patients continue to use it after they go home or to an after-care facility.
If a discharged patient enterers the yellow zone, the team following up with the patient notifies the physicians, who may adjust medications.
For HF patients, all follow-up calls are done by a HF coach—a new full-time position that IU Health Ball Memorial leaders instated in fall 2010. The coach calls discharged HF patients three times within the first week to make sure they are following up with appointments and understand their medications.
"The heart failure coach really is the link between the patient and the hospital after the patient goes home," Gorman says. "She makes sure they understand when their appointments are and that they're able to pick up and identify medications. It helps keep the patient engaged and accountable for their care, rather than just being a bystander."
UPMC Hamot makes follow-up phone calls to HF patients within 72 hours of discharge and refers all patients to its heart failure clinic.