Bridging the Gap: Enhancing Communication Between Hospitals and Patients to Prevent Readmissions

Hospital readmissions can be a significant challenge, often stemming from gaps in communication between healthcare providers and patients during and after hospitalization. Improving this vital aspect of healthcare communication is not just a key to preventing readmissions but also a cornerstone for embedding patient-centered care. Numerous actionable strategies to enhance communication and build a stronger bridge between hospitals and patients exist that we have seen work well:

The Critical Role of Communication

Effective communication is a linchpin in healthcare, especially when it comes to preventing hospital readmissions. Here's how hospitals can strengthen their communication strategies:

1. Patient and Family Engagement

Engaging patients and their families as active partners in care is critical to both facilitate and efficient discharge and reduce the potential for readmission:

Opportunities for communication: provide patients and families with a patient-centered process in which they can hear and discuss the progress towards discharge, discharge needs and viable options.
Open Dialogue: Encourage open communication, listen to patient and family concerns, and address questions promptly. Identify gaps in understanding or knowledge and how to support decision-making.
Family Involvement: Involve family members in discussions about care plans and post-discharge instructions, recognizing their role in providing support. Establish clear understanding of the care needs required and the potential family support available. Identify and understand the differences between immediate post-discharge needs and those of long-term care.

2. Clear and Comprehensive Discharge Instructions

The discharge process is a pivotal moment where patients receive crucial information for their post-hospitalization journey. Hospitals should utilize:

Plain Language: Ensure that discharge instructions are written in clear, plain language that is easily understandable by patients of varying health literacy levels.
Provide a clear set of Specific, Measurable, Achievable, Reasonable and Time-Bounded goals and tasks for patients and families to complete in order to optimize discharge and minimize the potential for readmission.
Multimodal Communication: Use a combination of written, verbal, and visual communication methods to convey information, accommodating diverse learning styles. Where possible provide visual aids ad infographics to accompany test results and reports. to help with post-hospitalization information sharing.

3. Health Literacy Initiatives

Promoting health literacy is fundamental for effective communication:

Patient Education Programs: Develop and implement ongoing patient education programs to enhance health literacy and empower individuals to actively participate in their care.
Plain Language Materials: Provide written materials, including brochures and pamphlets, in plain language, with visual aids and accessible formats.

4. Collaboration with Primary Care Providers

Strengthening communication between hospitals and primary care providers is essential for continuity of care:

Timely Information Sharing: Ensure timely and comprehensive sharing of patient information with primary care providers, facilitating seamless transitions and coordinated care.
Care Coordination Meetings: Consider engaging primary care providers in care coordination meetings to discuss patient progress and address any emerging issues. While this may seem impractical, we were involved in one feasibility study that recorded to an encrypted USB a video of the final Structured Interdisciplinary Bedside Rounds (SIBR rounds) interaction for a patient's in-hospital stay.

5. Regular Follow-Up

Consistent follow-up is instrumental in ensuring that patients remain on the right track after discharge:

Post-Discharge Phone Calls: Establish a system for post-discharge phone calls to check on patients, address concerns, and reinforce key elements of their care plans.
Remote Monitoring: Utilize remote monitoring devices to track patients' vital signs and health status, intervening when necessary to prevent potential complications.

6. Medication Management

Communication about medications is crucial for preventing adverse events and readmissions:

Medication Reconciliation: Conduct thorough medication reconciliation at admission and discharge, educating patients and families/carers about changes in medications.
Pharmacy Support: Collaborate with pharmacists to provide medication support, ensuring patients understand their prescribed medications, the potential side effects and what they should do if they become concerned.

7. Engaging Technology

Leveraging technology can significantly enhance communication and engagement:

Patient Portals: Provide access to patient health record portals where individuals can review their medical records, access educational materials, and communicate with healthcare providers. Ensure an adequate use of notification alerts and supports to optimize patient adherence to new medication regimens.
Telehealth Services: Implement telehealth services for virtual follow-up appointments, allowing patients to connect with healthcare professionals without the need for in-person visits.

Conclusion

The road to preventing hospital readmissions is paved with effective communication. By prioritizing clear and personalized communication, leveraging technology, implementing robust follow-up strategies, and fostering collaboration between hospitals and primary care providers, healthcare organizations can create a culture of patient-centered care that extends beyond the confines of the hospital. Ultimately, building a stronger bridge between hospitals and patients is not just a strategy for reducing readmissions; it's a commitment to promoting better health outcomes and empowering individuals on their journey toward wellness.