Phase 2 Video Reflection Summary
I enjoyed studying how to prevent all-cause hospital readmission because this is
particularly important to me in my hospital practice. I often get so frustrated when
pieces seem to be missing when a patient is being discharged. I do all I can to ensure
my patients are set up for success, but some aspects, such as relying on patients to
make follow-up appointments and wondering if they will follow through, are not always
within my control due to various social determinants.
A notable example is a patient’s ability to access transportation to their follow-up
appointments. Sometimes they mention this to me, and I will involve case management
in helping them set up a transportation opportunity through their health insurance.
Other times, I may get a patient who is homeless, and I don’t want to discharge him to
the streets. I want to make sure he gets to a shelter. Then, I ask myself where he will
be getting his medication refills, or if he will at all. There can be numerous barriers.
Sometimes, it is simply a matter of providing effective communication to the patient and
caregivers. Discussing medications, including why they need to be taken, for how long,
and any adverse effects to report to their healthcare provider, is crucial. Luckily, our
hospital has a follow-up telephone call system in place to reach out to patients at
discharge to address some of the issues that may arise. Sometimes, it is simply calling
them and providing them with a primary care visit at our hospital until they can establish
their own primary care doctor.
I would say that setting patients up for successful discharge and preventing hospital
readmission is one of the most important things we can do in healthcare. It was
reassuring to see that evidence-based research was being followed as closely as
possible at my hospital, which reinforced my commitment to ensuring that all aspects of
readmission prevention are addressed when a patient is discharged.
