Ensuring patients have access to necessary post-discharge services is critical for facilitating recovery and preventing readmissions. There are several strategies healthcare providers can utilize.

First, providers must conduct comprehensive discharge planning which assesses what services each patient will need after leaving the hospital such as medication management, wound care, physical therapy, skilled nursing, home health, etc. This planning should ideally begin on admission so there is sufficient time to coordinate everything. During the planning process, providers need to screen for any social determinants of health risks like food/housing insecurity which if unaddressed could negatively impact outcomes.

Second, providers need to verify that patients being discharged have all the necessary medical equipment, supplies, medications they require as well as instructions for how to use everything and who to contact with any questions or issues that arise. This often involves working with durable medical equipment companies, pharmacies, and home health agencies to ensure everything is in place and operational by the time patients leave.

Third, providers need to conduct patient education prior to discharge regarding their diagnosis, treatment plan, warning signs that should prompt contacting a provider, and how to self-manage their condition at home. This education often involves multimodal teaching methods like verbal and written instructions plus return demonstrations to evaluate comprehension. It is also important for education to involve family members or caregivers who will be assisting patients.

Fourth, providers need to make timely post-discharge follow up appointments with primary care providers or specialists, as appropriate, before patients leave the hospital. This involves direct scheduling of appointments which may require addressing any transportation barriers. Following up within 7-10 days of discharge has been shown to reduce readmissions. Additional interventions like transitional care clinics or in-home visits can help bridge the time until a follow up appointment occurs.

Fifth, providers need to leverage technology and community resources to support patients post-discharge. This includes ensuring patients enroll in remote monitoring programs if applicable for their condition and prescribed treatments which allow providers to keep tabs on vital signs and progress from a distance. It also means ensuring patients are aware of and connected to any applicable community-based support programs for things like Meals on Wheels, food banks, transportation assistance, adult day care, homemaking help, support groups, etc.

Sixth, providers need robust discharge communication with outpatient providers including primary care physicians and specialists. This involves sending timely and comprehensive discharge summaries that detail the hospitalization, procedures, treatments, changes to medications or treatments, follow up needs, and open clinical questions. Strong bidirectional communication helps outpatient providers take over care seamlessly and addresses any gaps preemptively.

Seventh, healthcare systems and institutions need to closely track metrics like 30-day readmission rates, ED visit rates, and patient/family experience surveys specifically focused on transitions of care in order to identify gaps, continually refine processes, and ensure accessibility of post-discharge services according to community need. This may require facilities partnering with community organizations, expanding existing programs, or piloting new initiatives based on data trends.

By implementing comprehensive discharge planning that begins early, verifying patients have necessary medical equipment and instructions, conducting proper patient/caregiver education, making timely follow up appointments, leveraging technology and community resources, sending robust communication to outpatient providers, and closely tracking post-acute outcomes – healthcare providers can significantly improve patients’ access to vital post-discharge services needed for recovery and meeting their goals of care. Coordinated, patient-centered planning from admit to well after discharge is key.