As a patient, one of the most tenuous experiences is being admitted to a hospital. In the course of treating the condition and heading toward recovery, patients are often seen by several different providers – many of whom have never seen the patient before. In addition, patients undergo various procedures and are subjected to transfers between units or even facilities. Upon discharge, patients and their families receive various, often complicated instructions, which they are expected to retain and then carry out at home. As an example, a typical Medicare patient could be given a handful of new prescriptions to fill along with educational materials related to the condition, reminders of appointments to make within the coming weeks, and various referrals.
With so much to juggle, it’s no wonder patients have a difficult time properly managing their care when released from the hospital. In fact, many of them – about one-fifth of Medicare fee-for-service patients – end up back in the hospital within the first 30 days. However, many of these readmissions can be prevented with the support of an integrated care coordination team.