Hospitals are stepping up their efforts to monitor patients after discharge to reduce readmission rates that can lead to Medicare penalties.
When the CMS rolled out its various quality-based incentive programs, Roper St. Francis Healthcare started focusing on patients who regularly used the emergency department. Often, those patients didn't have a primary-care physician, said Dr. Todd Shuman, chief physician officer at the Charleston, S.C.-based system.
Roper established the Care Transitions Program, which helps elderly patients recognize symptoms of health decline and assists them in managing their medications. The hospital deploys pharmacists to explain prescriptions to patients, and pharmacy technicians conduct medication reconciliations, Shuman said. That might include a call to the local pharmacy to find out the last time a patient filled a prescription.