Nobody likes going to the emergency room, or worse, staying in the hospital, but all too often panicked caregivers and frightened patients end up there. People who have recently been in the hospital are especially vulnerable.

Dr. Jyothi Rereddy, at WellMed at Breckenridge near Plano, Texas, is passionate about helping patients stay out of the emergency room and hospital, and follows a set protocol to help them heal at home.

First, Dr. Rereddy knows communication is key. She stresses the importance of frequent communication with patients, especially those who have recently been discharged from the hospital.

“We keep tabs on who is home from the hospital and I have staff calling them,” Dr. Rereddy said. “These patients should be seen in person within seven days of discharge, if possible, and by phone within three days after discharge. From there, we follow up once a week.”

Patients often go to the emergency room because of pain or fear that something isn’t right, so Dr. Rereddy and her team make sure patients know what to expect after surgery or a serious illness.

“We explain to them what is normal and what is not normal,” Dr. Rereddy said. “A patient who’s just had bypass surgery will be swollen and have some chest pain. We also tell them what is not normal; if the same patient is having shortness of breath, that is not good.”

Dr. Rereddy also gets to know her patients, and their family and caregivers, as much as possible. That way, she knows their situation, such as if they need more help at home.

“We had one patient who lived alone,” she said. “We knew that and arranged for him to go to his daughter’s home after being discharged. A lot of older adults need extra care.”

Another way to avoid readmission includes making sure patients understand their discharge orders.

“Say they have gall bladder surgery and end up with more medications,” Dr. Rereddy said. “They get discharge instructions, but often, don’t understand. They may get home and go back to their old medication.”

That’s how the follow-up calls and visits help. Dr. Rereddy will tell the patient to not make changes before talking to her. She reviews the discharge instructions with the patient and their family or caregiver, and because they are more comfortable talking to the primary care physician they know and trust, they absorb the information better and aren’t too intimidated to ask questions.Dr. Rereddy also encourages everyone at the clinic become familiar with each patient.

“It’s a team effort,” she said. “The whole office, from front to back, knows our high-risk patients, and we get to know who the patient prefers talking to.”

A newer strategy that helps aid clinic-patient communication at WellMed is the GrandPad, tablet devices designed for older adults. A pilot program started in spring in Corpus Christi, Austin and El Paso, all in Texas.

WellMed lends GrandPads to high-risk patients when they’re discharged from the hospital or skilled nursing facility, and teaches them how to use it. The device helps patients manage their appointments, attend telemedicine visits and ask any questions they may have.

A lower-tech tool that Dr. Rereddy uses is a loyalty folder.

“We gave the folders to all of our high-risk patients,” she said. “It has resources such as our cards, a reminder to call us first, information about Comfort Care (a transportation benefit), a personal statement from me that says, ‘I’m committed to you,’ and other resources.”

In the end, it all comes down to good communication.

“The whole responsibility is ours,” Dr. Rereddy said. “We should be connecting with them.”