The Post-Hospital Follow-Up Visit: A Physician Checklist to Reduce Readmissions

Eric A. Coleman, MD

To help newly discharged patients avoid hospital readmission, primary care physicians seek to accomplish a great deal at the follow-up ambulatory visit. This issue brief offers a checklist to help make this important encounter most effective.

October 2010

The post-hospital follow-up visit presents an ideal opportunity for the primary care physician to prepare the patient and family caregiver for self-care activities and to head off situations that could lead to readmission.

This issue brief, based on extensive research and interviews with clinicians, offers a proposed checklist to help guide the encounter. It is divided into three sections: prior to the visit, during the visit, and at the conclusion of the visit. The checklist includes all of the key activities for the primary care physician or other clinician. It is intended to be compatible with the typical outpatient clinic routine and to suggest how time may be used most efficiently and effectively.

A centerpiece of the visit is a medication reconciliation that takes the prehospital regimen into account. The "teach-back" technique is recommended as a way to ensure that patients understand instructions for taking their medications, managing their condition, and watching for "red flags" that could signal a worsening of their illness. In particular, patients and caregivers need to know how to reach the practice for emergency and nonemergency after-hours care.

The issue brief also presents suggestions for setting up the practice for efficient communication and collaboration between a patient's hospital physician and the primary care practice.

The complete issue brief can be found under Document Downloads.

Reader Comments

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- Steven Birenbaum, CHCF Senior Communications Officer
I would also encourage a review of the patient's mental status and a referral to a psychologist for support and/or adjustment to any changed status