Plans include identifying patients at risk for return, scheduling follow-up doctor's appointments before patients are discharged, sending nurses to patients' homes within a few days of discharge, monitoring patients at home, and educating patients and families with the hospitals taking more of an active role...Aetna and Kaiser both have pilot programs in the works...identifying high risk readmission patients...BD
Hospitals are taking steps to prevent the most common risk to patients after discharge: landing back in the hospital due to complications that could have been prevented with better follow-up care.
"We have to start paying attention to people's needs beyond the hospital door," says Mary Naylor, a professor at the University of Pennsylvania's School of Nursing. She has conducted a number of clinical trials on a model to help older adults with complex care needs after they are discharged. "The experience of multiple hospitalizations can take a devastating toll on the human psyche and the quality of life for patients and their caregivers," she says.
Both Aetna and Kaiser Permanente, the California-based managed-care giant, are working on pilot programs based on Dr. Naylor's model. Her studies show that discharge planning and home-care services for at-risk hospitalized elderly patients can reduce readmissions, lengthen the time between discharge and readmission, and cut the cost of providing care.
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