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Key Considerations for Post-Discharge Appointments

Follow these key considerations in your post-discharge appointments to help lower readmission rates in value-based care.

Moses Ting avatar
Written by Moses Ting
Updated over 2 weeks ago

Clinical Considerations

Review of Hospital Course and Pending Tests

Conduct thorough review of the hospitalization, including diagnoses, procedures, unresolved tests, and labs requiring follow-up.

Comprehensive Medication Reconciliation

Ensure accurate reconciliation of all medications, with attention to patient comprehension, affordability, access, and adherence.

Patient Management

Active Coordination & Communication

Position primary care as central to care coordination, ensuring timely referrals, information exchange, and a unified plan of care.

Education Using the "Teach-Back" Method

Confirm the patient has an understanding of the care plan by having them (and/or their caregivers) restate key instructions in their own words.

Assessment of Social & Functional Barriers

Evaluate SDOH considerations (e.g. transportation, food security, caregiver support, home safety) that influence care plan success.


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