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Leaving Well

Leaving Well

Hospital readmissions are roadblocks to better health. Here’s what we do to help you avoid them.

One hospital stay is difficult enough, but when obstacles in your life prevent you from fully recovering, one stay can lead to another. Not only is it inconvenient, but it can also be a serious risk to your health.

“Missed follow-up appointments, missing medications, lack of transportation to and from appointments, and failure to understand treatment can all lead to hospital readmissions,” said E. Coy Irvin, MD, chief medical officer at Archbold. “The risk of complications increases the more time patients spend in the hospital. By reducing readmissions, we’re not only improving their health, we’re lowering their healthcare costs and improving their quality of life.”

“Some other common factors that can cause readmissions include lack of a primary care provider, complex medical needs and inadequate care coordination,” added Amy Griffin, MSN, RN, chief nursing officer at Archbold. “Reducing hospital readmission rates requires active engagement and communication with all healthcare providers, nurses, frontline staff, patients, and their families.”

Empowering Patients

Archbold has implanted a number of measures to ensure patients understand why they were admitted to the hospital initially, how to manage their condition and how to get necessary follow-up care. We use practices spelled out in the Re-Engineered Discharge (RED) toolkit, an evidence-based program to reduce readmissions developed with funding from the federal Agency for Healthcare Research and Quality, including:

  • Calling patients within 72 hours of discharge to review their discharge plan
  • Offering home health services and nutritional education after discharge to help patients manage a chronic disease
  • Providing educational materials specific to a patient’s condition that highlight early warning signs that a condition may lead to readmission
  • Using our Meds to Beds program to provide patients with medication, instructions and other information about medications before discharge

Providers also check that patients have a primary care provider to whom they can go for further care.

“We make sure the discharge summary is sent to the follow-up physician,” Dr. Irvin said. “We have the doctors talk with each other directly, and we give explicit instructions to the patient to avoid confusion.”

We’re on Your Team

“Our readmission committee is a physician-led, multidisciplinary team that works continuously to prevent readmissions by identifying risk and barriers,” Griffin said. “We review our readmission rates monthly and use that information to develop tools that will allow us to continually improve upon them.”

Knowledge is Power

After you or your loved one has an inpatient hospital stay, it’s important to plan for discharge and recovery. Specific health needs and goals, the type of care received, and other factors will determine the specifics of a successful discharge plan, but some basic principles can help ease recovery and reduce the risk of readmission. One of the most important things your can do is gather information.

“Prevention of readmission should begin the day of discharge,” Dr. Irvin said. “In terms of importance, patients should consider asking questions during discharge on the same level as getting prescriptions and attending follow-up visits.”

Before you or a loved one leaves Archbold, ask about the following:

  • Overall health – How has you or your loved one’s condition improved since the procedure or treatment? Is there anything you should be aware of?
  • Medications – What medications were prescribed, and why? Are there any side effects to be aware of?
  • Potential risks – What are some complications from your or your loved one’s condition, treatment or procedure? Who should you call if you think something is wrong? At what point should you return to the hospital for further care?
  • Follow-up care – Have follow-up appointments been scheduled? What will you need to bring?
  • Life at home – What is a realistic time frame for recovery and a safe return to normal activities? Will you need assistance from a home health provider?

Another recommendation: Don’t wait until the day you or your loved one leaves the hospital to start these conversations with the care team.

“Preventing hospital readmissions should begin with a discharge plan at the time of admission,” Dr. Irvin said. “Patients need to understand when discharge will occur and what their role in discharge will be.”

Do you have a primary care provider with whom you can discuss your care? Visit to find one close to you.