There’s essentially a 1-in-5 chance that a Medicare patient will be readmitted within 30 days of being discharged from a hospital.
The U.S. government estimates $17 billion USD a year could be saved by preventing unnecessary readmissions through better care coordination, not to mention the improved quality of life and lowered infection risk for patients who don’t have to go back to the hospital.
Under new federal rules, hospitals with readmission rates considered too high now carry risk of having portions their Medicare reimbursements withheld.
The hospital discharge summary is an important document to aid communication that can prevent unnecessary returns to the hospital. If incorporated into an effective workflow, it helps open a window of opportunity for patients and their normal care teams to get on the same page with the hospital on next steps, such as making follow-up appointments, monitoring to prevent complications, managing a new medication regimen, etc.
So, if each hospital creates a better discharge process, we will tackle the readmission problem, right?
The problem, especially in metropolitan areas, is that patients go to several providers, and a few different hospitals. Therefore, the needed care coordination cannot be confined to one hospital alone. It needs to be spread across the community, including the patient, the patient’s primary care provider, specialists, and in some cases, non-traditional health workers. And to do that efficiently, communities need to standardize the discharge document as well as some targeted post-discharge interventions.
That’s the fundamental premise behind an important project that a small Intel team joined in the metropolitan area of Portland, Ore. We were honored to work with a team led by Melinda Muller, MD, of Legacy Health, who directs a pilot to standardize the discharge summary and process.