TMF works with patients, providers, government agencies and other groups to promote high quality health care.
August 31, 2015

Scheduling Follow-up Doctor Visits Helps Patients Avoid Swift Readmission to Hospital


Download Word file.Download Word File (English Release)


Download Word file.Download Word File (Spanish Release)



Emilie Fennell
(512) 334-1649
1-800-725-9216, Ext. 649

Austin, TX – May 10, 2010 — If you or someone you love enters the hospital, there’s a nearly one in five chance you’ll be back in 30 days, says Medicare. Especially vulnerable are patients discharged with a chronic illness such as heart failure or kidney disease or after a surgical procedure. (After surgery Medicare patients are often readmitted for conditions such as pneumonia, heart failure or bacterial infections.)

“Readmissions are an epidemic of immense proportions—off the radar screen,” says
Dr. Harlan Krumholz of Yale University and an internationally recognized heart disease specialist. 

Not only is rehospitalization stressful for seniors and their families, it’s costly. But the good news is that up to 76 percent of Medicare readmissions that occur within 30 days may be avoidable.

So what can you or a loved one do? According to TMF Health Quality Institute, the Medicare-contracted Quality Improvement Organization (QIO) for Texas, there are some simple steps that you or a caregiver can take to help prevent avoidable rehospitalizations.

“Probably the three most important things you can do are, first, make sure you have a follow-up doctor’s appointment scheduled before you’re discharged from the hospital. Second, know what medications you should take after you leave the hospital and how your medication routine has changed from before you entered the hospital. And third make sure you have received and understand your written discharge instructions,” says Jennifer Markley, RN, Director of the Lower Rio Grande Valley Care Transitions project, part of a federally-funded pilot program for the Centers for Medicare & Medicaid Services aimed at reducing avoidable hospital readmissions.

The project places the Valley, together with 13 other select communities nationwide, on the leading edge of a national effort to improve patient safety and reduce avoidable hospital readmissions. “The Valley will teach us a lot. You will inspire and challenge the rest of us,” said Dr. Krumholz at a TMF-sponsored meeting in Brownsville last January.

What you can do

Take a more effective role in your health care. If you don’t have a primary care physician, or even if you do, ask the hospital to help you schedule a follow-up visit before you leave the hospital. By asking the hospital to help you schedule this appointment, you accomplish several things:

  • You show you are serious about playing an active role in ensuring your health improves.
  • You help your physician provide better care for you by letting him or her know you have been hospitalized and what care you received while you were in the hospital.
  • You encourage those providing care for you at the hospital and those at your physician’s office to communicate with each other about your condition so they can better coordinate your care.
  • You may be able to get in to see your doctor sooner if the hospital requests the appointment.
  • You are less likely to let too much time pass before making an appointment if you schedule the follow-up doctor’s visit before you leave the hospital.

Dr. Joanne Lynn, a bureau chief in the Department of Health, Washington, D.C., and an advocate for including older patients in the dialogue for deciding their own health care says, “For the chronically ill, the hospital becomes a part of your life, instead of somewhere you go to get fixed.” She encourages people with chronic conditions to take steps to help avoid the disruption to their lives that the ordeal of being rehospitalized may cause.

Other steps you can take to avoid readmission within 30 days

To avoid a hasty rehospitalization, patients and caregivers can also take these steps:

  • Ask for a discharge instruction sheet and make sure you can explain the instructions in your own words.
  • Know what medications you will be taking and how much of each you should take after you are discharged and any changes to the medication plan you had before you were hospitalized.
  • Make sure you know how to obtain your medications. If you are worried about the cost, ask the hospital if there are generic substitutions or how you might receive assistance paying for medications.
  • If you have heart failure, ask if there is a heart failure clinic you can attend. Know what to do if a problem or something unexpected occurs and who you should call.
  • If you have been hospitalized multiple times and your condition doesn’t seem to be stabilizing or getting better, you may want to ask for help deciding if you should consider palliative care (care that focuses on making the best of each day during the last stages of illness).

“By scheduling follow-up visits, knowing your medications—how you will get them, what they are and how much to take—and by making sure you have and understand written discharge instructions , you can greatly increase your chances of getting better after a hospital visit,” says Markley. “And that’s what hospitals, Medicare and patients all want.”

Few people would disagree with the argument that it’s no fun to be rehospitalized after a serious illness or surgery. To avoid the emotional and financial trauma of rehospitalization and help ensure a more positive long-term outcome, take an active role in your health care.

About TMF Health Quality Institute
TMF Health Quality Institute is a nonprofit consulting company focused on promoting quality health and health care through contracts with federal, state and local governments, as well as private organizations. TMF partners with health care providers in a variety of settings to ensure that every person receives the appropriate care, every time.

TMF has received Independent Review Organization accreditation from URAC. TMF is a GSA Advantage Contract Holder.