4 steps to maintaining communication after discharge

By Mary Kay Thalken
09:00 AM

It's no secret that engaging patients in their care is essential to supporting care quality, increasing patient satisfaction and, ultimately, achieving positive patient outcomes. However, when the patient leaves the hospital, it can be challenging to sustain patient engagement, especially when it comes to maintaining communication and overseeing care continuity.

Despite the changing healthcare environment, hospitals and post-acute providers remain relatively disconnected from one another, making patients and their families primarily responsible for following care plans developed in the acute setting. As such, engaging patients and their support system in post-acute care is paramount to maintaining the patient’s recovery or chronic disease management and limiting the potential for avoidable readmissions.

Though patient and family engagement can be tough once a patient is “out of sight,” hospitals can pursue the following four steps to facilitate communication, continue oversight and ensure patients follow their care plans.

Step One: Help the Patient and Family Understand the Diagnosis

Whether an inpatient stay is the result of an office visit or a trip to the emergency room, patients typically don’t expect to be in the hospital. They may be confused, surprised and emotional, on top of whatever ails them, and they may not fully accept or understand their condition. Therefore, it is essential for hospital staff and physicians to communicate with the patient and his or her family about the diagnosis in an effective and timely manner—as patients’ understanding and acceptance of their condition is the foundation of their involvement in post-acute care. Without clear understanding and acceptance, patients may forego follow-up appointments, stray from diets or stop taking prescriptions or therapeutic treatment, all of which can be detrimental to the patient’s recovery or chronic disease management.

To determine a patient’s understanding of and ability to manage health information, hospitals should assess the patient’s health literacy and readiness to learn through conversations with the patient and family. Especially in a time of anxiety where there is the potential to be overwhelmed with new information, it is important to educate and communicate with patients in the most preferred and effective manner for them, whether that be through one-on-one conversations, phone calls, emails, printed literature, videos, web sites or other resources. Be sure to respect language preferences during this time, refraining from assuming the preferred language and instead asking what language is preferred and using that consistently.

Step Two: Ensure the Patient and Family Are Committed to the Care Plan

Many patients need help following their care plans after discharge and rely on family to manage prescriptions and other aspects of health. The family also plays a vital role in keeping the patient healthy by offering emotional support, relieving anxiety and reinforcing healthy decisions. For these reasons, it is important for the patient as well as any caretakers to know not only what the care plan includes but also what’s expected of them to make sure the patient continues down the path of recovery. When all involved are committed to their roles and expectations, the patient is more likely to meet key milestones in his or her recovery, contributing to better outcomes. 

Again, by using targeted communication and educational tools, hospitals can facilitate discussions with patients and families to ensure they know the next steps in the patient’s care. In addition, taking time to have patients and families demonstrate medication administration techniques or other self-administered treatments can confirm that all parties fully understand how to sustain treatment over time.

Step Three: Keep the Patient and Family Actively Involved in Care Transitions

In a time when patients and their families may feel helpless, urging them to be directly involved in care decisions and transitions is one way to keep them engaged and empowered—an important component of long-term patient satisfaction.

An effective way to involve patients in care transitions is to leverage discharge and care coordination technology to connect patients with possible post-acute providers while the patient is still in the hospital. Automated solutions can streamline care transitions by conveniently delivering key information about post-acute providers, enabling patients and families to make informed decisions quickly and easily. While manually arranging post-acute care transitions can take days, care coordination and discharge technology helps hospitals obtain responses from area providers in as little as 30 minutes, allowing patients and family members to efficiently review their options, identify preferred providers and make choices without having to add unnecessary days to a patient’s stay or associated expenses. 

Step Four: Leverage Technology to Continue Patient Oversight

As mentioned before, patient engagement efforts shouldn’t stop when patients leave the hospital. In fact, the post-acute care setting is one of the most critical times to communicate with patients, as they may forget care instructions or find it difficult to adapt to new demands or change old habits. Technology can make it easier for hospitals to keep patients, families—as well as providers—focused on the patient’s care and working toward the same goal. For instance, care coordination and communication platforms offer support to patients and their families by sending reminders and tracking recovery progress through social media, email, text messaging and other tools. This allows hospitals and providers to stay virtually connected with their patients, monitoring progress and overseeing care long after discharge.

Helping Patients Help Themselves

As the healthcare model evolves, the patient’s role in and responsibility for following care plans after discharge will continue to increase, and hospitals will need to find ways to help patients help themselves.

By providing patient-focused education before discharge and using technology to maintain communication after the patient leaves the acute setting, hospitals can stay in touch with their patients, allowing them to monitor patient progress and proactively intervene when milestones in the care plan aren’t met. Getting patients and their families actively engaged in and committed to their post-acute care plans can not only can limit preventable readmissions, it can reduce overall healthcare costs while also achieving better patient outcomes.