Anatomy of a Readmissions Master Plan
Enhancing case management, sharing data, and linking to community partners are some of the organizational improvements Memorial Hermann has made, but some of the largest gains involved closing the more practical gaps that can trigger readmission, such as those related to:
Durable medical equipment: Some patients with a catastrophic illness or injury may require a substantial number of durable medical devices, often for the first time. The team found that patients would frequently be sent home before the DME was ready, says Josehart—so rather than just making a DME referral, the staff now manages the transition.
"Our standard is that all the equipment needed to care for a patient in the home is in the home 24 hours prior to discharge so the family has a chance to make sure that it's there, that it's working, to test it, and if it's different from what they expected, to resolve that issue prior to the patient going home. That's something that we track in our internal quality metrics. Although it's a home thing, we see that as part of our commitment to making sure that we're handing off to a safe environment," Josehart says.
Medication reconciliation: Even before discharge, the nurses and case managers work to ensure that the patient and family understand their medication, even something as seemingly simple as recognizing changes in shape or color of a medication, Metzger says. Whenever there is a question, a staff pharmacist is brought in to explain the new medications and any potential interactions. The team also makes sure the patients have enough medication to take home with them so they don't have to rush out in those first few days to get a refill.
"We have a relationship with Walgreens so that when we have patients we know will be leaving the hospital with a new prescription, they can opt to have a Walgreens that is located on our campus bring those prescriptions directly to their room so that in fact they don't have to try to stop at the pharmacy or have something delivered to their home," Metzger says.
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