Numerous studies have found that patients who leave the hospital are at great risk of returning to the hospital within the first 60 days following their discharge. Indeed, the Patient Protection and Affordable Care Act, the health care reform act enacted into law earlier this year, includes several provisions intended to encourage patients and their health care providers to do a better job of transitioning patients from the hospital to home.
Many of these patients are Medicare beneficiaries, many of whom have chronic illnesses such as diabetes that with depressing frequency land them into the hospital, again and again. A study released last year found that one in five Medicare patients are rehospitalized within one month.
Medicare’s “Care Transitions” program identified some of the top risks faced by patients who have been recently discharged from the hospital:
- Medication problems. Patients on a dozen or more drugs forget which ones they're supposed to toss when given new ones in the hospital, or can't afford the new ones, or have no way to pick them up.
- Not getting a follow-up doctor's visit within a week of discharge. Waiting longer is proven to increase rehospitalization. Yet even if patients have a primary care doctor, getting a rapid appointment can be tough.
- Not realizing early signs of trouble and knowing what to do about them.
Rehospitalizations aren't just bad for patients, but for taxpayers, too. They're costing Medicare $17 billion a year, a recent study estimated. How can these “rehospitalizations,” as they are called, be prevented or minimized?
For patients who are being discharged from the hospital, the federal government has published Taking Care of Myself: A Guide for When I Leave the Hospital. This easy-to-read guide can be used by both hospital staff and patients during the discharge process and provides a way for patients to track their medication schedules, upcoming medical appointments, and important phone numbers.
The U. S. Department of Health and Human Services’ Agency for Healthcare Research and Quality, AHRQ, has the guide available online, so it can be printed. AHRQ Director Dr. Carolyn Clancy says, “Before you leave the hospital, you and a nurse or doctor should work together to fill out sections of the guide. You should also bring it with you to any follow-up medical appointments.”
AHRQ urges providers to:
- Talk with patients about the information in the guide.
- Confirm that patients understand instructions by asking patients to describe, in their own words, what they will do when they leave the hospital (e.g., when and how they will take their medicine, when they will go to their doctor's office).
- Give the patient a copy of the completed guide to take home and instruct them to take it to future medical appointments.
Patients should:
- Become familiar with the information covered in the guide before you enter the hospital.
- Make sure that the information about you in the guide is correct (e.g. medication allergies, contact information, primary care provider information).
- Study the guide with your clinicians to make sure you or your family members understand everything that is in it and how to care for yourself when you get home.
- Take the guide to your future medical appointments.
When patients leave the hospital, the Guide explains, there are a lot of things they need to do to take care of themselves: “You need to see your doctor, take your medicines, exercise, eat healthy foods, and know whom to call with questions or problems. This guide helps you keep track of all the things you need to do.”
For an introduction to Taking Care of Myself: A Guide for When I Leave the Hospital, visit
The Guide is also available in Spanish.