Q&A: Tools for patients to manage their health after discharge

Q: Do you have any techniques or methods patients can use to manage their health after a hospital discharge?

A: Case managers as care coordinators lead in healthcare innovation as government and commercial payers move to the population health model. Case managers can influence avoidable costs and create partnership with patients and families, providers, and payers. Reaching out beyond the acute care stay, case managers in the hospital coordinate care to encompass medication reconciliation, arrange physician appointments, and assess for home safety (Jonas et al., 2012). Healthcare systems recognize the need to enhance and assist their patients’ transition from hospital to home, both while in the hospital and after discharge.

Patients do not respond to uniform teaching styles. They require disease education tailored to their spe­cific needs. Patient activation is a term used to describe the knowledge, skills, confidence, and resources patients possess to manage their disease state in an active and informed manner. The patient-centric approach meets patients at their personal level of readiness to learn and accomplish the health-related goals. Patients with the highest level of activation display interest and involvement and actively decide upon their best course of action. A high patient activation level is associated with decreased healthcare costs (Hibbard, Greene, & Overton, 2013; Hibbard, Mahoney, Stock, & Tusler, 2006).

One tool a patient can use that does not measure patient activation but is a useful metric for the patient to track are biometric markers that are important to him and to his progression in managing his disease states. For example, a patient with diabetes may want to monitor his or her HgbA1C to demonstrate the improvement in his management of diabetes. The patient health record is a patient-centric document that consists of ele­ments critical to facilitating safe care transitions, including:

• An active problem list
• A list of medications and allergies
• A list of red flags or warning symptoms that correspond to the patient’s chronic illnesses
• Space for the patient to record questions and concerns

The patient may also record upcoming appointments in his or her small record book. Many patients may choose to use an electronic tracking system for the above-listed important information. The tool should be geared toward the patient’s comfort level, so it is not as much the tool that is important, but that the patient is using some type of tracking tool to manage their disease state.

For more information, see Case Management Guide to Population Health. Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.