Top patient engagement strategies for hospital discharge

Designing a personalized care plan

According to the National Human Genome Research Institute under the NIH umbrella, personalized medicine is “an emerging practice of medicine that uses an individual's genetic profile to guide decisions made in regard to the prevention, diagnosis, and treatment of disease. Knowledge of a patient's genetic profile can help doctors select the proper medication or therapy and administer it using the proper dose or regimen.”

Personalized care plans forego one-size-fits-all philosophies and acknowledge that patients will need different care that is customized to their genetic, clinical, social, and lifestyle needs in order to thrive.

In addition to genomics, healthcare organizations can use risk scores and clinical information to create a personalized care plan. In theory, this best sets patients up for success in their clinical journeys toward well-being.

Personalized medicine is a key opportunity for improving patient outcomes and patient engagement in the long run, but the data show that personalized medicine is still elusive.

In 2023, researchers at Yale found that the algorithms used to create these personalized care plans aren’t always generalizable to the patient population. In order to perform well, these algorithms need to be both accurate and generalizable, the researchers said.

Providers also struggle to take into account the lifestyle measures that could help them tailor care plans. In the 2022 State of the Healthcare Consumer Report from Kaufman Hall, researchers explained that patients want personalized, tailored care encounters, but providers can’t account for all of the lifestyle data and information patients are poised to provide to get there.

Opening stronger lines of patient-provider communication, leveraging social determinants of health (SDOH) screening, and tapping more interoperable consumer-facing technology could be the first steps to creating the personalized care plans that could yield better clinical outcomes.

Communication & education

The cornerstones of any good hospital discharge process are communication and education. Without explaining key facets of a patient’s diagnosis and the aftercare management plans necessary for preventing poor outcomes, patients will not be prepared to go home.

Providing strong patient education will also be essential to closing out a good patient experience. Patient education helps empower patients and make them feel safe and comfortable.

Patient education needs to be a core part of patient-provider communication, most experts agree. Strategies like patient teach-back, explanations that consider patient health literacy levels, and shared decision-making will be essential. To ensure strong patient activation, healthcare providers may consider using motivational interviewing.

But efforts need to go beyond verbal communication, too. After all, data show that patients forget about half of what they hear during a medical encounter. Providing patient education materials and good discharge summaries will give patients a reference point once they return home.

The most useful discharge summaries will be written in lay language and be free from too much medical jargon. Data indicate that clinical notes written with too much medical jargon can be confusing for patients and sometimes obscure medical directions.

In terms of patient education materials, healthcare organizations should consider helping patients parse through the best online resources while also cultivating their own library of tools. Surveys have shown that patients want access to these kinds of patient education tools but that most provider offices don’t have a large offering.

At the heart of these efforts needs to be cultural competence and responsiveness. Medical advice that does not consider a patient’s cultural norms may not be integrated into the patient’s everyday life. Providers need to partner with patients to determine the most realistic and effective care management for a patient’s cultural and lifestyle needs.

Support family engagement & education

Patient engagement during hospital discharge should not just involve the patient. Where applicable, it should also involve family members and other caregivers. After all, family members are often the ones who help patients manage their recovery once they leave the hospital.

To that end, each patient engagement strategy practiced on patients should also be practiced on the family members by their side. Aftercare education, post-discharge instructions, and other care coordination efforts need to loop in caregivers.

There are documented benefits to involving the family or caregiver in a patient’s post-discharge recovery.

A 2022 study showed that family engagement and education were instrumental in improving home care among a chronically ill population. Researchers posited that this was because of the supportive role family members play when patients manage their care at home.

Overall, family engagement and education have proven to cut hospital readmission by 25 percent, a separate 2017 report showed. Researchers said most family members become at-home caregivers, so providing instructions about different recovery techniques helps improve patient safety.

Support access to follow-up care

Follow-up care is central to any post-discharge care plan. Follow-up care gives healthcare providers the opportunity to assess the progress of patient recovery and affords patients the opportunity to raise any potential concerns.

Data suggest that access to follow-up care helps prevent poor clinical outcomes. In 2022, researchers wrote that access to follow-up care within seven days of discharge for an acute hospitalization resulted in reduced risk of rehospitalization.

But separate data have shown that access to follow-up care is left wanting.

In a 2020 analysis published in JAMA, researchers found that 29 percent of Medicare beneficiaries aged 65 and older did not have an ambulatory follow-up visit within 30 days of emergency department discharge; 60 percent did not have a follow-up appointment within a week.

Healthcare leaders are testing out various systems for engaging patients in follow-up care. A 2024 Health Affairs analysis of the Camden Coalition’s model of care coordination and management increased access to ambulatory follow-up care by 56.5 percent.

Other studies have indicated that telephone patient outreach could encourage patients to go in for their follow-up appointments. Phone calls can assess patient recovery and can also be used as a means to deliver patient education.

Of course, assessing for SDOH will be essential here. Some patients may not access follow-up care because they lack transportation access or cannot take time off work.

Many organizations have begun offering appointments during non-traditional office hours to account for patients with unique schedules and have designed interventions, like rideshare partnerships, to overcome these barriers. However, SDOH screening will help providers determine who needs referral to these programs.

Adopt remote patient monitoring & communication tech

Healthcare’s push toward digital solutions has introduced healthcare providers to a category of tools to help them manage care outside the hospital or clinic: remote patient monitoring (RPM).

According to the Agency for Healthcare Research and Quality (AHRQ), RPM “is a type of telehealth in which healthcare providers monitor patients outside the traditional care setting using digital medical devices, such as weight scales, blood pressure monitors, pulse oximeters, and blood glucose meters.”

Once collected, that data flows into the EHR for providers to assess for care management. When abnormal readings occur, healthcare providers can intervene. This can be effective both for chronic disease populations and patients recovering at home from hospitalization, a practice that was popularized during the COVID-19 pandemic.

Right now, the data is scant as to whether RPM actually decreases rehospitalizations or mortality. One study has shown that RPM tools are more commonly adopted by younger White patients who are already at low risk for hospital readmission, so addressing technology access and digital health literacy disparities could change things.

Another 2021 study showed that although RPM tools didn’t make a difference in rehospitalization or mortality, patients enrolled in RPM programs did have their providers course correct their treatment plans more often, indicating that the tools are working as intended.

Set up patient feedback mechanisms

Once the patient is back home, it is important for providers to get status checks. Patient feedback allows providers to tweak care plans as necessary.

Some of that feedback can be obtained using the RPM tools outlined above. When a blood pressure cuff produces an abnormal reading, a provider can communicate with the patient and they can work together to course correct.

Patient-reported outcomes (PROs) can supplement—or, when necessary, replace—the insights that RPM tools offer. PROs look at how a patient feels after a procedure or healthcare service and help measure the efficacy of care in the context of the patient’s everyday life.

“PRO tools measure what patients are able to do and how they feel by asking questions,” the National Quality Forum says on its website. “These tools enable assessment of patient–reported health status for physical, mental, and social well–being.”

PROs may be a way for healthcare providers to tailor a treatment course to a patient’s personal needs and priorities, particularly by zooming in on functional status and quality of life.

“Ensuring that patients and families are engaged as partners in their care—one of the CMS priorities— can also be an effective way to measure the quality of patient care,” according to the Centers for Medicare and Medicaid Services (CMS). “Although patient reports of their health and experience with care are not the only items that should undergo measurement, they are an important component.”

Collecting PROMs (patient-reported outcomes measures) may be promising, although the data is scant about how PROMs affect clinical outcomes. In one study from the Patient-Centered Outcomes Research Institute (PCORI), researchers found that implementing PROMs in cancer centers was acceptable to patients.

Nearly all (96 percent) of patients who completed a PROM survey said the survey was easy to complete, and 97 percent said the PROM was easy to understand. Around three-quarters of all patients completed the PROM without a reminder, while 14 percent completed the PROM after a nudge.

In pursuit of better clinical quality measures, more patient-centered care, and lower healthcare costs, healthcare organizations need to assess how they can keep patients out of the hospital. By practicing strong patient engagement among recently discharge patients, organizations can reduce the risk of a key patient population.