Effective care management is essential during the first 30 days after discharge to prevent unnecessary readmission and associated costs. Care managers can follow a 10-step readmission reduction program to help patients stay on track with recovery and avoid acute care:
Call the patient within two days of discharge.
Assess the patient’s self-care capacity.
Frontload homecare and ensure patient ‘touches’, if appropriate.
Conduct a home safety evaluation.
Order and install durable medical equipment prior to discharge.
Order an emergency alert/medication reminder system and preprogram important phone numbers on patient’s phone.
Implement fall prevention program, intervention, and education.
Provide in-home education on new diagnoses or unmanaged chronic conditions.
Connect the patient with community resources.
Establish a best practice for follow-up phone calls after discharge.