Post-Discharge Care: New Models to Improve Recovery

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Post-Discharge Care: New Models to Improve Recovery

November 7, 2019

With increased emphasis on value-based care, patients and care givers alike are focused more than ever on the complete cycle of healthcare, especially when discharged from a hospital stay. Post-discharge care continues to be at the center of many provider programs to help sustain quality service while increasing patient satisfaction and decreasing readmission rates.  




Timely follow-up is particularly important for senior citizens, as on average 20 percent have been diagnosed with a chronic disease, which increases the likelihood of ongoing care after they return home after discharge.  Now, a new model is now being tested and has proven successful among senior citizens.  The general concept includes a focused care team led by a nurse and a social worker, all in the comfort of the patient’s home. A few hospitals are exploring this new methodology, and initial results are very positive.

Here are 10 tips – from Becker’s Hospital Review – for hospitals considering such a program.

  1. Assure that there is trusted interaction between the outpatient care team and the hospital discharge planners. 

  2. Begin the patient-interaction portion of the program with a post-discharge in-home assessment.  

  3. Once the in-home assessment has been conducted, the nurse practitioner and social worker should meet with the primary care physician

  4. Conduct weekly interdisciplinary team conferences.  

  5. Provide specialized care and considerations for common geriatric conditions. 

  6. Consider the unique physical and psychosocial needs of low-income seniors including dual-eligibles. 

  7. Focus not only on treating a person's medical condition but for managing a broad array of care needs across multiple settings. 

  8. Ensure that your program includes a focus on patient education

  9. Have the information technology infrastructure in place. 

  10. Continue to monitor the patient's progress.


There are many items to consider when exploring such a post-discharge model.  The quickest way to explore such a program is to implement a robust post-discharge callback program.  Using trained professionals equipped with modern technology, hospitals can quickly accelerate a powerful post-discharge program that will enhance the overall patient experience, especially when returning home after a hospital visit, and in many cases, help improve patient satisfaction.


PREMEDEX helps hospitals across the United States explore and implement innovative post-discharge care programs.  Contact us today so we can learn about your objectives and how the PREMEDEX team can help you launch a better program to improve post-discharge care.


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