Project RED: Module 3: The Re-Designed Discharge Process: Patient Admission and Care and Treatment Education: Slide 27
Conducting Post-Discharge Activities
- Transmit discharge summary and Patient Care Plan to PCP
- By fax: Ensure it is received and legible
- By e-mail: Ensure it is received
- Follow-up phone call to patient 48 to 72 hours after discharge
- Caller uses script that assess understanding of medication and follow-up appointments
- Need for second call by clinician determined
The last components of the re-engineered discharge program focus specifically on post-discharge followup. Ensure that the discharge summary and perhaps a copy of the Patient Care Plan are provided to the PCP in a timely fashion. Depending on the mode of transmission, you may need to confirm receipt and legibility.
Consider the phone call placed to the patient 48 to 72 hours after discharge as a clinical call. You are assessing the patient's status after he or she has been home a couple of days. After asking the patient how he or she is feeling, ask if he or she:
- Has questions about the information in the Patient Care Plan.
- Has filled his or her prescriptions.
- Is taking the medications.
- Is taking any medications that are not on the list that was given at discharge.
- Has specific medication questions.
- Will be able to keep the follow-up appointments that were scheduled.
The caller may also need to arrange a second call by a pharmacist, physician, or case management.
Your hospital will need to decide if this call should be documented and where that documentation will be stored.