Hospital re-admissions within 30 days may occur due to an unrelated diagnosis or a planned course of treatment, but they are coming under increased scrutiny due to the perception that some re-admissions are the result of poor care or a lack of coordinated care and may be avoidable. In order to help patients heal without complications that may result in re-admissions, the Partnership for Patients (PfP) Initiative has set the following goal:
By the end of 2013, preventable complications during a transition from one care setting to another will be decreased so that all hospital readmissions would be reduced by 20% compared to 2010. Currently Naval Medical Center’s readmission rate is 8% with a preventable readmission rate of 2-3%. This is dramatically below the national average.
While no agreed upon criteria exists to define preventable re-admissions that might be preventable and those which might not be preventable, it is generally accepted that many could be avoided by developing a more cohesive plan of care that is clearly communicated to the patient and family upon discharge. The key components of this effort are medication reconciliation, communication handoff, post-discharge access and post-discharge plan of care. Below is what you can expect if you are a patient:
- Education about your diagnosis throughout the hospital stay.
- Make your follow up appointments.
- Discuss with you any tests or studies that have been completed in the hospital and discuss who will be responsible for following up on the results.
- Organize your post-discharge services.
- Confirm your medication plan.
- Review the appropriate steps for you to take if a problem arises after discharge.
- Provide your primary care physician with a copy of your discharge summary.
- Provide you with a copy of your written discharge plan at the time of discharge.
- Provide telephone reinforcement of the discharge plan and problem-solving two to three days after discharge.