Timeliness of outpatient follow-up: an evidence-based approach for planning after hospital discharge.
Patients with multiple complex chronic conditions, who account for the
great majority of readmissions among Medicaid and Medicare
recipients nationally,
21
stand to benefit considerably from timely follow-up. For those whose
readmission risk exceeds 20%, our analysis suggests
that 1 readmission may be prevented for every 5
patients who receive outpatient follow-up within 14 days. These patients
are
characterized by having 3 or more chronic
conditions, often including advanced coronary artery disease, chronic
obstructive
pulmonary disease, chronic renal failure,
congestive heart failure, diabetes, ischemic vascular disease, or a
history of organ
transplant, dialysis, or total parenteral
nutrition. In this statewide Medicaid population, however, only 51% of
patients
in high-risk categories received follow-up within
14 days, and for every high-risk patient who did not receive follow-up,
there was a low-risk patient who did. Healthier
patients and those with greater social support or self-management skills
may
be better equipped to secure and attend an earlier
follow-up appointment, but potentially at the cost of delaying care for
those with more complex needs.
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