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Home > HIN Case Studies
Hospital Discharge Improvement Guide: How to Close Six Key Care Gaps and Reduce Readmissions
Hospital Discharge Improvement Guide: How to Close Six Key Care Gaps and Reduce Readmissions
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The hospital discharge is not a finite period of time but rather an ongoing process requiring planning and precision. Without a coordinated approach, the exit from the hospital can be fraught with risk and result in adverse events and unnecessary readmissions.

The Hospital Discharge Improvement Guide: How to Close Six Key Care Gaps and Reduce Readmissions delivers dozens of tactics to tighten the six major gaps in the hospital discharge process:

  • Education
  • Test Management
  • Follow-Up & Discharge
  • Communication
  • Physician Accountability
  • Health Literacy

Contributing presenter Susan Shepard, director of patient safety education at The Doctors Management Company, suggests skills and interventions that health plans, hospitals and physician practices can use to improve each of these critical areas of the hospital discharge process. She also presents two key mechanisms for encouraging patients and caregivers to participate in and manage their care.

In this 25-page special report, Shepard also shares best practices from hospital discharge-focused interventions that are already reducing readmissions for hospitals and health plans around the country:

  • Boston University's Project RED (Re-Engineered Discharge);
  • BOOST toolkit from the Society of Hospital Medicine;
  • Transforming Care at the Bedside from the Institute for Healthcare Improvement (IHI); and
  • Hospital to Home (H2H) from the American College of Cardiology.

Increasing scrutiny by CMS of hospital readmission rates is prompting healthcare organizations to reevaluate each stage of the care continuum. From the three key questions to ask the patient at discharge to learning how to red-flag patients at high risk for readmission, the Hospital Discharge Improvement Guide: How to Close Six Key Care Gaps and Reduce Readmissions provides the practical and comprehensive processes healthcare organizations need to improve the efficiency and success of their hospital discharge planning process.

Table of Contents

  • A Coordinated Discharge Planning Approach to Reduce Avoidable Hospital Readmissions
    • Is Discharge a Dirty Word in Healthcare?
    • Reasons for Readmissions
    • Teach-Back and AskMe3 Methods
    • Four Ways IHI Is Transforming Bedside Care
    • Preventing Unsafe Transitions
    • Defining the High-Risk Patient
    • Resources for Improving the Hospital Discharge
    • Six Ways to Improve Communication with Patients at Discharge
  • Q&A: Ask the Experts
    • Case Manager Help with Reducing Repeat Hospitalizations
    • Whos Job is Discharge Planning?
    • Improving Post-Discharge Contact with Patients
    • Partnering with Pharmacies to Reduce Avoidable Readmissions
    • Financing Programs
    • HIPAA Compliance in Coordinated Care
    • Conveying Timely Discharge Data
    • How Healthcare Reform Will Help Prevent Readmissions
    • Pharmacists on Integrated Care Team
    • Who's Responsible for Medication Reconciliation?
  • Glossary
  • For More Information
  • About the Presenter
Publication Date: August 2010
Number of Pages: 25
ISBN 10: 1-936186-40-3 (Print version); 1-936186-41-1 (PDF version)
ISBN 13: 978-1-936186-40-2 (Print version); 978-1-936186-41-9 (PDF version)
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