top of page

Better Post-Discharge Follow-up Creates a Win-Win for Providers and Patients Alike

Updated: Jan 16, 2019

The U.S. Centers for Medicare and Medicaid Services (CMS) estimates that more than 2,500 hospitals in the U.S., (almost half the total number of 5,564 registered hospitals in the country), will face reduced Medicare reimbursement in FY 2018 under the Hospital Readmissions Reduction Program (HRRP). HRRP reduces payments to certain hospitals with excess readmissions. These reductions are estimated to amount to more than $564 million during the same year. Given this financial impact, along with the emotional and physical toll of readmissions on patients and their caregivers, it is not surprising that providers and related organizations continue to look for new ways to improve the discharge process. One recent study by the Boston University School of Medicine (BUSM) reinforces the critical role discharge planning can play in reducing readmission rates while increasing patient health and satisfaction. It also clearly demonstrates the importance of ongoing physician involvement in aftercare in helping to ensure the ultimate success of discharge plans.

In the usual discharge planning process, a physician develops the discharge plans but typically doesn’t make a home visit or continue to actively monitor a patient after discharge. In fact, many may never see the patient again.

But in this particular study, researchers found that when resident physicians visit the homes of their former hospital patients, they are better able to assess patient needs and understand the important role that community services and agencies play in keeping them at home and out of the hospital. A key element of the follow-up was a review of the original discharge plan and determining how effective it was in addressing the patient’s post-hospitalization aftercare and specifically which elements were beneficial and which elements were not.

The major take-away from this study was that improved assessment of patient needs and developing more personalized discharge plans, including medication reconciliation and caregiver communications, are key to more successful transitions from in-hospital care to at-home or SNF-care. While this study focused on older adults, its advocated approach could readily be used to improve the discharge plans and follow-up of younger patients.

The results of this BUSM study also reinforce other research suggesting that while patients are generally satisfied with their physicians, only 11 percent report feeling they have “all the time they needed” with them. Physicians are also feeling this “time crunch,” with only 14 percent reporting they feel they get enough time with individual patients. While time is, indeed, a commodity and in short-supply in most healthcare environments, it’s clear that spending time with a patient after discharge is just as important as the time spent while the patient is still hospitalized.

Another study reported by the National Institutes of Health suggested that better discharge-planning quality is associated with lower rates of hospital readmissions for those patients treated for heart failure, pneumonia, and partial or total hip replacement. In fact, there is significant evidence suggesting reduced readmission with improved discharge planning.

Discharge Plans Should Neither Start nor End when the Patient Leaves the Hospital

One of the most important elements of the discharge plan is the one that is generally not given sufficient attention. It is knowing what patients and their caregivers actually do with the discharge plan after leaving the hospital. After all, the best plan in the world quickly loses its value if it is not followed. This was also one of the elements highlighted by the BUSM study.

Generally, patients, once discharged, may no longer have the same level of constant monitoring they had while hospitalized. The end result is a higher risk that the discharge plan will be not be followed adequately (if at all) resulting in disease relapse and possible readmission. The benefits of appropriate monitoring post discharge include better overall treatment outcomes and increased patient satisfaction, which may positively impact reimbursement amounts.


There are several key challenges for enhancing discharge planning follow-up. One is operational and the other, as expected, is financial. Many providers simply do not have the resources to devote to staff time, data collection, training, and other logistical management required to ensure a successful discharge. On the financial side, there is still some uncertainty as to the exact return-on-investment of more comprehensive follow-up on discharge plans. Anecdotal evidence, however, suggests that they do result in a net cost saving.

Another important element to consider is that discharge planning should be viewed as a key element of the continuum of care offered by a provider rather than as a discrete process with clearly-defined end points. Some in the healthcare community have gone so far as to recommend not even using the term “discharge plan” and use others such as “care transition” or “continuity care” to better reflect patient necessity. This type of approach also tends to be more interdisciplinary with an integrated team of primary care physicians, hospitalists, pharmacists, physical therapists, community-based organizations and the patient’s personal caregivers. While facilitating communications and logistics across multiple players can be challenging, this may be the more effective in keeping patients healthy after they leave the 24-7 care of a hospital environment.

Steps Providers Can Take

As daunting as extending the discharge plan to include post-discharge elements may seem, it need not be. There is no such thing as a one-size-fits all approach to post-discharge planning. Providers can, and should, develop approaches that allow them to conduct the most effective – both in terms of cost and outcome – plans for their unique needs and patient population.

Some steps providers can take to enhance post-discharge planning?

  • Get creative. You may need to tailor the discharge instructions to fit the needs of individual patients and limit “medical speak.” One provider in West Virginia, for example, realized that some older patients have problems reading scales, which is an important aftercare activity for heart-failure patients to monitor fluid retention. The solution? Patients were instructed to try on their best Sunday shoes every morning. If the shoes fit, they were doing well. If the shoes didn’t, they most likely were retaining fluid and needed to call their doctor.

  • Involve caregivers. The Caregiver Advise, Record and Enable Act (which has been enacted in a majority of States), requires providers to involve caregivers and family members in discharge planning. Complying with this law clearly pays dividends as evidenced with some providers reporting up a 25 percent reduction in the risk of older patients being readmitted within 90 days of discharge.

  • Make medication a focus and not an adjunct. More than half of medication errors affecting over 1.5 million people occur during care transition, including discharge. It has been reported that almost half of all patients have a clinically significant medication error within a month of discharge. Clearly, patients and their caregivers need to be properly educated about the medications they are given upon discharge.

  • Tap volunteer and community support. Most providers have some type of community volunteer corps that helps with a wide variety of operational tasks. Consider expanding that network to conducting follow-up with patients after discharge or having them work in a post-discharge call center.

  • Pilot a variety of approaches. Academic institutions and healthcare organizations offer a wide variety of discharge planning tools and models. Providers should consider tapping these resources to help identify what could work best for them. Once identified, a pilot program would help in customizing the plan to an individual provider’s needs.

  • Look beyond the medical issues. There are other factors – that have very little or nothing to do with medicine per se – that impact post-discharge plan compliance and providers should consider these as well. These include such things as transportation to a doctor or pharmacy, safe housing, and community resources for social and other needs.

  • Adequately account for the cost of proper discharge services in the chargemaster. Providers should include the added costs associated with enhanced discharge planning to the total price they charge for medical services. The chargemaster is generally where the official rates for the various procedures and services charged by the hospital is located. It is also the basis for receiving payment from governmental and commercial payors.

To be successful, post-discharge planning and patient education need to go beyond a routine, cursory meeting at the time of discharge. This approach usually results in insufficient planning, poor instruction, lack of coordination and minimal follow-up. The end result is reduced patient satisfaction, higher readmissions, lower reimbursement for hospitals and poorer patient health. By taking a more holistic, integrated and transitional approach to this critical element of hospital care, providers can create a true ‘win’ for themselves, their patients and their communities

Joy Stephenson-Laws is founding and managing partner of Stephenson, Acquisto and Colman (, the law firm of choice for the healthcare industry and the leader in healthcare reimbursement law. To date, the firm has recovered well over $1 billion in unreimbursed, denied or disputed medical claims. In this role, Ms. Stephenson-Laws leads a diverse team of over 100 professionals that includes attorneys, doctors, nurses, technology and healthcare provider operations specialists. Ms. Stephenson-Laws was awarded the B.A. from Loma Linda University and the Juris Doctor from Loyola University. She is a member of the American Bar Association, Consumer Attorneys of Los Angeles, California State Bar Association, U.S. District Court-Central/Eastern, and the Ninth Circuit Court of Appeals.


bottom of page