Chief Nursing Officer
Rooks County Health Center
When it comes to clinical quality, we identified several problems with our readmissions and we have been able to meet guidelines on lowering readmissions. We have a social worker who we now have call all of the patients and do follow-up surveys.
The day patients come in, we start discharge planning. We find out what they will need, what they have in place at home, what types of things we can set up to make it work for them. We get physical therapy, occupational therapy, speech therapy: We have them all evaluate our patients. Then our social worker does discharge planning reviews every two or three days until the patients are ready to go home, and we meet with all of the multidisciplinary people to make sure that all things that we can identify are identified. When they are discharged, we call and ask, "Did you get your prescriptions? If you're getting services, have they showed up? Are you able to function at the level you thought you should be able to function at?"
This is a small community and we know the patients and we know the families and we know where some of the weak links might be. Not everything is right here in our hospital and available for all of our patients. But before they go home, we have it set up and ready for them.
In our April Intelligence Report, the top challenge cited by leaders for their primary care redesign efforts is to get patients engaged in their own care. Why is this so difficult, and what steps is your organization taking in this area? E-mail John Commins at firstname.lastname@example.org to be featured in this future Council Connection piece.
John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.