Part I: Four Steps to Maintain Patient Engagement after Discharge

Posted by Mary Kay Thalken, RN, MBA on 4/28/14 11:24 AM

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Editor’s Note: This is the first of a two-part blog series. Read the second blog here.

Engaging patients and families in post-acute care is vital to the patient’s recovery.It's no secret that engaging patients in their care is essential to care quality, increasing patient satisfaction and, ultimately, achieving positive patient outcomes.

But when the patient leaves the hospital, it’s challenging to sustain engagement, maintain communication and oversee care continuity.

Despite our changing health-care environment, hospitals and post-acute providers remain relatively disconnected, making patients and families primarily responsible for following care plans. Engaging patients and their support system in post-acute care is paramount to maintaining the patient’s recovery or chronic disease management and limiting avoidable readmissions.

Though patient and family engagement can be tough once a patient is “out of sight,” hospitals can take the following steps to facilitate communication, continue oversight and ensure patients follow their care plans.

Step One: Help the Patient and Family Understand the Diagnosis
No matter how they got there, patients typically don’t expect to be in the hospital. They may be confused and anxious, on top of whatever ails them, and may not fully accept or understand their condition.

It’s essential for hospital staff and physicians to communicate about the diagnosis effectively and quickly with the patient and his or her family. Without clear understanding and support, patients may skip follow-up appointments, stray from diets or stop taking prescriptions or treatments—which of course can be detrimental to recovery or chronic disease management.

Assessing the patient’s health literacy and readiness to learn, through conversations with the patient and family, is imperative. Particularly during a time when it’s easy to be overwhelmed with information, it’s important to educate and communicate with patients in their preferred manner—whether one-on-one conversations, phone calls, emails, printed literature, videos, websites or other resources.

Also be sure to respect language preferences by asking what language is preferred, and using it consistently.

Step Two: Ensure the Patient and Family are Committed to the Care Plan
Many patients need help following care plans after discharge and rely on family to manage prescriptions and other aspects of health. The family also plays a vital role in keeping the patient healthy by offering emotional support, relieving anxiety and reinforcing healthy decisions.

So it’s important for the patient and caretakers to know not only what the care plan includes, but also what’s expected of them to make sure the plan is followed. When all involved are committed to their roles and expectations, the patient is more likely to meet key milestones in recovery, contributing to better outcomes.

Again, by using targeted communication and educational tools, hospitals can facilitate discussions with patients and families to ensure they know the next steps. Taking time to have patients and families demonstrate medication administration or other self-administered treatments can confirm that all parties understand how to sustain treatment over time.

Making the Time
As a career-long practicing nurse, I understand that time and resources are limited at hospitals. So taking the time to educate patients and families about the care plan is challenging.

But there are resources to help. Read a blog from one of my colleagues about how care coordination technology enables hospitals to focus on higher risk patients and family engagement, to promote better outcomes.

And stay tuned for my blog next week for the last two steps to maintain patient engagement after discharge.

Topics: Post-acute Care, Care Coordination, Care Transitions, Patient and Family Engagement, Reducing Readmissions