Keeping an eye on discharged patients

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.

The University of Colorado Health's Memorial Hospital assigns a case manager to follow up with patients at risk of heart failure, stroke, pneumonia or heart attack, said Dr. Patrick Faricy, chief medical officer at the Colorado Springs hospital. As at Roper, Memorial's pharmacy technicians do medication reconciliations with patients and check to see whether they are taking the drugs they were prescribed at discharge. Memorial staff keep patients' primary-care doctors abreast of any hospital admissions and meds ordered.

Providers increasingly are using mobile technology to track patients post-discharge. The Hospital for Special Surgery in New York City is developing a mobile application that will allow staff to interact with patients remotely post-discharge, said CEO Louis Shapiro. The app will update hospital staff on patients' recuperation, such as how well they're walking.

To reduce readmissions, providers must change their thinking, recognizing that patients are never fully discharged, said Dr. Chris DeRienzo, chief patient safety officer at Asheville, N.C.-based Mission Health. Patients move between inpatient, outpatient and post-acute-care settings, and it's essential to apply best-practice interventions at every level to make the greatest impact, he said.