Being admitted to a hospital can be an overwhelming experience for your patients. Your patients’ priority after hospital admission should be a smooth recovery, and as a Primary Care Physician (PCP), you can do your part to help them.
The key is communication. After a patient is discharged, he or she should schedule a follow-up visit with you as soon as possible – typically within seven to 30 days of discharge (depending on the diagnosis). Research has shown that patients who follow up sooner – or at all – after hospitalization have significantly lower readmission rates.
We recommend your scheduling team hold a few appointments open for recently discharged patients. Also, when patients call to make appointments, ask your team to ask them if they were recently discharged from a hospital stay. If so, ask your team to schedule a visit for them to come in within seven days of their discharge.
When a visit is scheduled, consider these practices to minimize a patient’s risk of readmission:
Send reminders. People can be forgetful, especially with everything that goes on after a hospitalization. To ensure your patient follows through with his or her visit, send him or her reminders via email, text or phone; that way, you stay top of mind.
Review his or her history during the visit. Given a patient’s medical history, is there a high risk that he or she will be readmitted? You know your patient best. Review his or her history and identify different factors that increase that risk and work with your patient to address these issues.
Make sure he or she understands any discharge instructions. If the hospital staff did not send you information regarding the hospitalization, talk to your patient about his or her discharge instructions as well as any medications he or she may have been prescribed. If the hospital did send you this information, go over it with the patient. This can help prevent medication interactions and encourage medication adherence.
Have questions about preventing readmissions? Call the AvMed Provider Services Center at 1-800-452-8633. The Provider Services Center is open from 8:30 p.m to 5 p.m., Monday to Friday (excluding holidays). You can also get in touch with the Center by sending an email to Providers@AvMed.org. More resources can be found at AvMed.org under the Provider section.