Staying healthy after a hospital visit: the critical role of transitional health care

Seeing your family doctor after a hospital visit can lead to better health outcomes

Millions of Americans who leave the hospital are readmitted within 30 days. But studies have shown that effective transitional care can help keep them home, which leads to better long-term health outcomes. One in 6 Medicare patients are readmitted to the hospital within 30 days after discharge, according to recent data (Opens in new window). Unfortunately, many patients do not receive the support they need.

After being discharged from a hospital or urgent care facility, patients are at a higher risk of complications, readmissions and poor health outcomes.

Transitional care, ideally managed by your family doctor, is a critical but often overlooked component of the health care system. Transitional care includes activities such as medication management, scheduling follow-up appointments, coordinating with primary care providers and identifying and addressing social determinants of health.

Q. Why are hospital readmission rates so high?

One in 6 Medicare patients are readmitted to the hospital within 30 days after discharge. That’s millions of people. It doesn’t have to be that way. After being discharged from a hospital or urgent care facility, patients are at a higher risk of complications, readmissions and poor health outcomes. There should be more emphasis on transitional care to reduce readmissions. Unfortunately, many patients do not receive the support they need.

Q. How can we reduce hospital readmissions and help people stay healthy at home?

Transitional care, ideally managed by your family doctor, is a critical but often overlooked component of the health care system. It’s a key priority here at WellMed and Optum.Transitional care includes activities such as:

• A review of medications
• Scheduling follow-up appointments
• Coordinating with specialists and primary care providers
• Identifying and addressing social determinants of health, such as food insecurity

When practiced properly, care transition can significantly reduce hospital readmissions, improve patient satisfaction and lead to better long-term health outcomes. It’s vital that follow-up appointments with your primary care physician and other members of your care team are scheduled before you leave the hospital.

Q. Can you share some best practices for patients after an emergency room or urgent care visit?

Educating patients and caregivers on specific health conditions, medications, and self-care before they leave the ER or an urgent care visit is important. This is where your primary care physician can play a critical role.

Schedule a follow-up appointment with your primary care doctor within a few days of the ER or urgent care visit. Discuss the reason for the visit, any new diagnoses or treatments, and ensure your primary care provider has all the relevant information.

Q. Do you have any tips to help patients communicate with their health care providers?

Be prepared for your appointments. Make a list of your questions and concerns ahead of time. Bring your medications, health history, and any relevant documents. Consider bringing a family member or friend to help remember information. Communicate openly and honestly. Share all relevant information about your symptoms, health history, and lifestyle. Don’t be afraid to ask questions if you don’t understand something.