2020年8月6日,

House Call Conversations: Avoiding Hospital Readmissions

Learn how closely-monitored post-discharge care can prevent patient readmission.

当慢性, multi-comorbid patients are discharged from the hospital there is a 26% chance they will be readmitted within 30 days, according to a Medicare Payment Advisory Commission report to Congress. The report also shows that 75% of those instances are preventable. Multiple studies support that a patient’s best shot at avoiding readmission is to receive closely-monitored post-discharge care.

 

The Value of a lg游戏 Post Discharge Visit:

  • Nearly 80% of engaged lg游戏 patients have one or more post-discharge visits within 30 days compared to 55% of non-engaged patients.
  • Engaged lg游戏 patients with a post discharge visit following completion of an inpatient stay had an almost 60% lower risk of readmissions than those without a post discharge visit.

 

出院后护理的障碍 

Patients often fail to comply with a recommended post-discharge visit to their primary care provider.  This can be due to inadequate transportation, 健康的错觉, scheduling availability with the PCP office, 等等. 不管原因是什么, one thing is certain; if a patient doesn’t have medications reconciled after a hospitalization, or a medical professional tracking their post-hospital stability, the risk of readmission and increased health care spend rises significantly.

 

 

4 Ways lg游戏 Can Help Minimize Readmission Risk:

  1. While a patient is hospitalized or placed in a skilled nursing facility, a lg游戏 nurse care manager communicates with the patient’s acute care team. lg游戏 shares baseline information on the patient’s comorbidities and ensures the hospitalist, 专家, 和PCP护理计划是一致的.
  2. Following a hospital or facility stay, lg游戏 relays detailed notes back to the PCP, highlighting critical information that the PCP may use in follow-up care.
  3. lg游戏 may assist the patient in scheduling a post-discharge office visit with their PCP and help arrange transportation to their visit.
  4. lg游戏 strives to provide a thorough in-home visit within 72 hours of discharge. In a lg游戏 post-discharge visit, the provider (i.e. medical doctor, nurse practitioner or physician’s assistant) evaluates the patient and:
    • 调整药物
    • Educates patient on his/her individual readmission risks and symptoms
    • 跟进实验室情况
    • Oversees home health vendors ordered by the hospital
    • Evaluates for and manages hospital-acquired infections
    • Communicates with PCP and 专家s involved in the care

 

从医院到家庭的个性化护理

Patient condition after an acute hospitalization often changes quickly from day-to-day. Having a lg游戏 provider in the home immediately following discharge – with regular follow-up visits over the subsequent weeks/months as the patient returns to baseline – allows us to thoughtfully adjust medications and provide care in concert with the patient’s evolving condition. All home visit notes are shared with the PCP.

When needed, lg游戏 becomes a bridge for patient care from the hospital to home. With 24/7 patient access and through strong community relationships, lg游戏 provides an additional layer of support to chronically ill patients and their PCPs, to ensure safer transitions home after hospitalizations and rehabilitation stays.

A PCP sharing patients with lg游戏 can call on a lg游戏 provider to perform in-home evaluations of their program-eligible patients whenever they are unavailable. lg游戏 answers calls 24 hours per day, 一年365天, helping catch problems early to reduce hospitalizations. lg游戏’s care team consists of providers, 行为健康专家, 药剂师, 社会工作者, 营养师, 护士护理管理者, 关怀协调员和大使. 点击这里 to learn more about collaborative complex care with lg游戏.