Baylor Scott and White Health System (BSW) in Temple, Texas, has a new program in place to avoid this. Unlike many programs that just help patients schedule follow-up appointments with primary care physicians, the discharge team at this organization not only helps patients make follow-up appointments with physicians, but also with any specialists the patients need to see as well, including cardiologists, pulmonologists, or even follow-up radiology appointments.
Physicians have long treated patients knowing that some of the problems keeping them sick were problems that medicine couldn't fix--lack of food, electricity, or money to pay for medicine. These are the types of problems that often send patients back to the hospital after they are discharged home. Today, some physicians can write a prescription to solve these problems the same way they order medicine.
Many hospitals have been adding group rounds as a means of improving communication and care for patients. These rounds give case managers (CM) an opportunity to better understand the patient's condition, learn about any potential factors that might extend LOS, and prepare for any potential barriers that might lead to readmission after discharge.
