By Christina Beach Thielst

First Posted at Christina’s Considerations on 5/6/2013

Christina Thielst, Host of Christina's Considerations

Christina Thielst, Host of Christina’s Considerations

The RWJF is working to bring some attention to improving transitions from the hospital to home environments and reducing readmissions with the Care About Your Care effort.  It highlights the revolving door syndrome with a report on  US hospital readmissions and an interactive map.

Some of the striking bits of data include:

  • Poor continuity of care after a patient leaves the hospital–especially for those with chronic conditions–leads to readmissions
  • More than a third of patients don’t get the tests, referrals or follow-up care needed after a hospital stay
  • Nearly 20% of Medicare patients return to the hospital within a month after discharge, costing $12 billion per year
  • Only 50% of patients rehospitalized within 30 days had a doctor visit before readmission
  • Poor care coordination was responsible for $25-$45 billion in wasteful health care spending in 2011

discharge preparation checklist and transition planning tool is a great reference for patients and their family caregivers.  The discharge preparation checklist can help patients and caregivers track all the information they should understand before leaving the hospital, including:

  • Overall care plan
  • Where the patient is going after discharge
  • Who to contact if a problem arises during transfer
  • Medication instructions and potential side effects
  • What symptoms to watch for
  • Necessary follow-up appointments

The care transition plan can help keep patients and caregivers keep track of important information in one place, including:

  • What symptoms to watch for and how to respond
  • Scheduled follow-up appointments
  • Contact information for hospital, primary, and home health providers, as well as pharmacy
  • Medications, what each does, and how to take each, and when to take each

Free continuing education resources for professionals is also available.