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The Importance of Tracking Patients Post-Discharge

September 12, 2017

When someone passes through the doors of a rehabilitation and nursing facility as a patient, they also come bearing their past. Any health changes due to operations, accidents, or regular aging are relevant during their treatment. Equally, when a patient leaves they don’t cease to exist. However for many medical facilities, this is exactly how a patient interaction is viewed.

The Allure Group has a simple, but effective solution. By tracking patients post-discharge, there is a threefold benefit: the patient recovery process is monitored, the correct health providers are communicating, and the caregiver or family has access to all the relevant information.

Patient recovery time varies case-by-case, but a healthcare professional can help set realistic expectations throughout the process. Patients may have questions about if they’re getting better, how long it will take, and the barriers to getting home quickly. Tracking just in the care facility can only answer so much of this scenario.

By maintaining contact between the medical facilities and the patient, a total roadmap of the patient process and recovery is clear to all. This minimizes surprises, eliminates contradictory information, and speeds up decisions. Even better, the complete cycle of knowledge is informed by clinical data collected from other post-discharge patients, so the process improves itself each time.

Melissa Powell, COO of The Allure Group, points out that medical facilities should be planning for discharge from day one. Once a patient is admitted, it’s essential to partner with hospitals not only at the executive level but at the line level. Contact between care facilities isn’t just one direction, but a two-way ongoing conversation.

Information on a patient must go back and forth between counterparts in different facilities to ensure the whole patient picture is clear to everyone, including the patient themselves. These details can come in before a patient is referred, when they’re in care, and after they leave. It’s a whole cycle with many moving parts, which can make it difficult to maintain communication across boundaries and timelines without a clear plan in place.

The final part of the trifecta of knowledge is the patient themselves. Someone who comes in for a first knee surgery may imagine that a second surgery will go exactly the same way. It is the job of every care provider, from hospital to rehabilitation center, to make sure the patient and family have realistic, informed expectations and can schedule their lives accordingly.

Any major health incident, such as cardiac events, can have complex, lengthy home care plans. Patients and their caregivers don’t always fully understand instructions when they leave the facilities. In some cases, it may not even be clear who the patient can call with questions.

Missed steps in the home care plan can lead to infection, skipped medications, and possible readmission to care. If a patient isn’t monitored after being released, it is too easy for these details to slip through the cracks. In some cases, the caregiver or patient also needs to be notified about upcoming appointments, prescription refills, or other milestones in recovery. By tracking patient data and experiences, it’s also encouraging patients to follow their care plans more completely.

The Allure Group calls this strategy “bundling,” and has published best practices on the subject. These best practices and guidelines are applicable even to smaller facilities that lack the corporate communication structure. No matter the size, by ensuring clear, consistent collaboration each facility is strengthened by the others.

The patient’s health and happiness are always the primary concern. It is an additional burden if they are also tracking their health information and explaining it again and again to each new health professional. Why not relieve them of this extra burden, and ensure that professional quality information is captured, communicated, and acted upon? The Allure Group sees this as an easy opportunity to improve health care from both sides, and has created a system for other groups to track patients post-discharge.

Categories: General