Anatomy of a Readmissions Master Plan
Discharge packets: One of the gaps that physician leaders noted in medication reconciliation failures was that patients did not understand their discharge instructions. That's no surprise, considering the volume and complexity of the material given to them, says Keith Fernandez, MD, president of MHMD Memorial Hermann Physician Network. "Historically our patients might go home with 30 pieces of paper," he says.
"It was hard for the patient to determine which piece of paper was the most important. And even the important ones were hard to read and in language that the average patient could not understand," he says.
A physician-led team spent a year organizing and editing down discharge instructions to a critical few and embedded those into the EHR. Now, discharge instructions are distributed consistently to every patient based on that patient's specific condition. "The group came up with a very streamlined process for discharges," Fernandez says. "In fact, the discharge process probably would qualify for a discharge summary as well. So when the patient leaves, they take home a relatively clean sheet of information that has everything critical in that process for the patient to know—and only that."
The secret, if there is one, is in effort and attention, Metzger says.
"There is no magic to this," she says. "It's paying attention to the details and it's making sure that the patient and the family always understand where they are in a trajectory. It is constant, precise execution on those kinds of things every single day."
This article appears in the November issue of HealthLeaders magazine.
Jim Molpus is Leadership Programs Director of HealthLeaders Media.
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