Patient-Centered Care Starts with Analysis

In addition to aligning with other local healthcare organizations to create a more seamless transition of care for these patients, Griffin also created a patient-centric discharge
plan, including:

• Literature written at a fourth-grade level that includes the name of the diagnosis at the top
• A patient “teach back” method so providers can be sure the patient understands his or her treatment and next steps
• A scale for the patient to check his or her weight
• A dry weight on the patient’s W-10, so the follow-up care provider will know the patient’s discharge weight (and if the patient is gaining or losing since hospitalization)
• The scheduling of a follow-up appointment with a physician prior to discharge
• A follow-up call within 48 hours of discharge and four subsequent calls

“We worked to engage the frontline staff in this effort,” says Charmel.

Planning and patience are important for those who pursue the patient-centered model. “You can’t take a scattershot approach; you need to take a broad approach to making this change to a patient-centered focus,” says Frampton. “It takes several years to get sustainable results [with patient-centered care] across all areas, and that takes a cultural change.”