Most organizations have gaps in basic service offerings known to improve outcomes, reduce errors, and facilitate inpatient-outpatient coordination. Here are five such gaps you can address now:

1. Identify and address non-clinical risk factors

Housing and transportation issues, language and literacy barriers, lack of social support, and other non-clinical challenges frequently confound high-risk patient care plans. Conducting in-depth psychosocial risk assessments for your highest-risk patients enables the care team to develop a better understanding of the patient's environment outside of the hospital, which in turn enables proper customization of the care plan, as well as the level and type of support provided.

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2. Ensure patients have an accurate medication list

According to the Pharmacy Executive Forum's 2017 Medication Reconciliation Benchmarking Survey, the average medication list has between five and seven discrepancies. The majority of these errors are errors of omission (especially problematic for high-risk drugs such as anti-epileptics), but dosing and frequency errors are also common. Overall, nearly 20% of medication errors are estimated to result in patient harm.

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Many of these errors can be averted by gathering an accurate medication list and completing medication reconciliation at every care transition. Ideally, every health system would have a pharmacy-led team dedicated to performing both of these medication-reconciliation tasks for all patients. However, that approach is unrealistic for most health systems. Consequently, it is important to train, organize, and deploy staff to maximize their effectiveness. Specialized teams with protected time fare best in terms of accuracy—whether those teams are comprised of nurses, pharmacy technicians, pharmacists, or some combination.

3. Arrange for patients to receive post-discharge medications before leaving the hospital

Nearly a quarter of patients discharged home fail to fill their prescriptions after being hospitalized. Progressive organizations have implemented med-to-bed programs to ensure that patients have their medications before leaving the hospital. This approach eliminates common barriers to filling discharge prescriptions, such as lack of transportation or long wait times at the pharmacy. As a result, med-to-bed programs not only help reduce readmissions, they also improve medication adherence and boost prescription revenue for the health system.

4. Follow up by phone post-discharge

To combat post-discharge errors and ensure patients have the support they need once home, many organizations offer telephonic care management support intended to surface issues that may arise between hospital discharge and a patient's next primary care visit.

In many cases, a nurse care coordinator will call patients within 48 hours post-discharge to ensure that the patient's immediate needs are met (e.g., access to medications, follow-up appointment scheduling). During that call, the nurse will also assess whether the patient needs additional specialized assistance and then triage to other centralized staff members, such as pharmacy, social work, or non-clinical support teams.

5. Use warm handoffs to connect the patient back to primary care

The transition from hospital to home is not complete until a patient is connected to his or her primary care provider for a post-discharge follow-up visit. During that visit, the care team should review the post-discharge care plan, assess the patient's recovery, ensure the patient understands his or her self-care plan—including any changes to his or her medication regimen—and resolve any outstanding issues (e.g., test results that were pending at discharge, follow-up tests recommended at hospitalization).

This visit closes the feedback loop and ensures that the patient has an ongoing source of care. Ideally, the provider would also be alerted in real-time of the admission, enabling him or her to coordinate with the hospital team.