How an Improved Discharge Experience Drops Readmissions

What happens to a patient when they are discharged and get home with a 25-page set of instructions? Transitions are happening at an overwhelming time for patients, a time when patients are not able to fully to understand their discharge instructions.

Now, through a holistic and comprehensive approach, 100% of eligible patients are contacted, creating a seamless continuum of care. Here’s a look at the process:

  1. We share visuals with the patient at discharge. Bon Secours Mercy provides a targeted handout and places a colorful information sticker on the patient’s discharge folder. The health system also posts messages on screens throughout the ED, telling patients to expect an automated follow-up call from the care team
  2. We survey with relevant follow-up questions. We’re not asking patient satisfaction questions. Through a brief assessment, we review the patient’s experience and care needs. We want to determine if the patient needs additional interventions such as help getting medication or help making an appointment with a primary care physician, if so the patient is escalated to Envera Health’s clinical team.
  3. We engage patients on the phone. A nurse will make an outreach call to the patient to review the discharge plan and any self-care instructions. The nurse also helps find additional resources such as financial aid and prescription help, as needed. We use a geotargeted phone number (not an 800 number) and a recognized caller I.D.

Envera Health agents work diligently with each patient, to be certain their needs are met. Below are real stories of prevented hospital readmissions:

Example 1

An elderly female patient visited the ER with a wounded toe. Her care team dressed the wound and gave her an antibiotic ointment. They told her to change the bandage every day and sent her home.

Once home, the patient realized she would not be able to change the dressing as instructed because of her weight and other comorbidities. She also lived alone. She considered going back to the ER to have someone replace her bandage.

Thanks to Bon Secours Mercy Health’s discharge process, a nurse was able to connect the woman with her primary care physician and schedule home health visits. This kept her from revisiting the emergency room.

Example 2

A male patient ended up in the emergency room after a sports injury. The physician told him he probably had a torn meniscus and referred him to an orthopedic surgeon. He was sent home with six painkillers.

Once home, the patient called to make an appointment with the orthopedist and learned he could not get in for several weeks. He did not have enough pain medication to last that long and was anxious about not returning to his job as a butcher.

He considered going back to the ER, but a nurse intervened. While on the phone with the patient, the nurse called another orthopedic practice and asked for a same-day appointment. She was able to get the patient in for follow-up care immediately. That kept him from making another ER visit.

Redesigning Transitions of Care: How Bon Secours Mercy Health is Creating a New Discharge Experience

In a Mid-Atlantic Market, Bon Secours Mercy Health has seen a 15% drop in their revisit rate over a 9-month period, an estimated reduction of 1,100 revisits to their ED. Envera Health’s transitions of care approach has allowed Bon Secours Mercy Health to put resources in place where they are needed most, letting their limited care management resources focus on higher clinical priorities.

To learn more about how Envera Health and Bon Secours Mercy Health created a new discharge experience, watch the webinar today!

Learn More