The Importance of Post-Discharge Follow-Up in Patient Outcomes

With consumers’ growing interest in their care, physicians and payors are increasingly seeing the benefits that greater involvement can have with regard to patient satisfaction and outcomes – even after discharge and especially when discharged directly home.

As consumers grow more involved in researching their care choices, physicians and payers are learning to channel that interest into improved patient satisfaction and outcomes – even after discharge and, especially, when the patient returns home.

That’s why payers should consider providers with innovative programs that engage patients and families in their care.

Research shows the benefits of post-discharge follow-up

While many strategies of increasing patient-centeredness are being applied during the patient’s time in the hospital, it is important to continue this level of care after discharge. Research on the subject reveals that:

• Patients that were hospitalized with acute conditions are less likely to readmit if they are contacted as part of an early follow-up program post-discharge.¹
• 20% of readmissions are likely to be prevented in patients with three or more chronic conditions if they are contacted by a provider of care within 14 days of discharge.² 

• There is no significant difference in satisfaction between nurse-led telephone follow-ups and outpatient visit follow-ups, suggesting that telephonic programs are effective patient engagement tools.^3,4

Implementing post-discharge follow-up services not only improves patient satisfaction, but can also reduce total cost of care over time as rehospitalizations or other major setbacks are prevented.

AfterCare program supports patients after discharge

The Kindred AfterCare program is designed to help recovering patients heal and to provide the support they need once they have discharged from our hospitals. Trained staff will review patients’ charts and reach out to patients 2, 7, 14, and 31 days post-discharge. They discuss durable medical equipment, medication needs and education, primary care provider appointments, continued progress and any additional post-discharge services needed. Patients are also able to reach registered nurses 24/7 within the first 30 days after discharging from our hospital. This program improves patient outcomes and satisfaction as well as reduces the rate of readmission.

Kindred strives to be a valuable partner for providers and payors alike and are committed to an innovative approach to managed care. We currently support the following contract products:

• Medicare Advantage
• Commercial
• Managed Medicaid
• Veterans Affairs
• Worker’s Compensation

Visit kindredmanagedcare.com to request a conversation about how Kindred's level of service can help manage your critically complex patients.

References

1. https://pubmed.ncbi.nlm.nih.gov/20442387/
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4369604/
3. https://bmccancer.biomedcentral.com/articles/10.1186/1471-2407-10-174
4. https://www.sciencedirect.com/science/article/abs/pii/S1462388910000840