Continuity and Coordination of Care after Hospital Discharge

Patients can become confused about when and with whom they should be following up after hospital discharge. Clear, written discharge instructions can improve compliance with follow-up. Have the nurse reviewing the discharge instructions with the patient validate the patient’s understanding of the actions they are to take for follow-up by verbalizing what they are to do. Explain to the patient why follow-up visits are so important. Asking hospital staff to assist in making follow-up appointments for patients before they leave the hospital can increase the incidence of timely post-hospitalization visits.

Additionally, PCPs should receive copies of discharge summaries to optimize patients’ continuum of care. Patients often return to the care of their regular community doctor after discharge. In cases where the hospital physician is not the primary care provider, requesting a copy of the discharge summary for the PCP is important.

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