What does an inpatient follow-up consist of?

Inpatient Follow-Up Components

Inpatient follow-up should include structured discharge communication with medication reconciliation, scheduled outpatient appointments arranged prior to discharge, patient education on "survival skills," and timely transmission of discharge summaries to outpatient providers—all coordinated to ensure safe transitions of care.

Core Components of Inpatient Follow-Up

Medication Reconciliation and Management

• All chronic medications must be cross-checked to ensure none were inappropriately discontinued during hospitalization 1
• Prescriptions for new or changed medications should be filled and reviewed with the patient and family at or before discharge 1
• For patients on insulin or significantly altered diabetes regimens, demonstration of medication dosing and marking of correct doses on dosing instruments reduces errors 1
• Pictograms and parental assistance with medication delivery improve adherence and reduce dosing errors 1

Structured Discharge Communication

• Discharge summaries must be transmitted to the primary physician as soon as possible after discharge, documenting medication changes, pending tests and studies, and follow-up needs 1
• Information should be accurately and promptly communicated to outpatient physicians to ensure continuity 1
• The discharge process should include checks for patient comprehension using "read-back, teach-back" strategies, where providers assess patient recall after each concept 1

Scheduled Follow-Up Appointments

• The inpatient team or case managers should schedule outpatient medical follow-up appointments prior to discharge rather than leaving this to the patient 1
• Appointment-keeping behavior is significantly enhanced when follow-up is scheduled before discharge rather than instructing patients to call for appointments 1
• For severely elevated blood pressure presentations, follow-up should occur within 1 week; for moderately elevated presentations, within 1-2 months 1

Patient Education ("Survival Skills")

The following areas must be reviewed and addressed prior to hospital discharge 1:

• Identification of the specific healthcare provider who will provide care after discharge 1
• Level of understanding related to the diagnosis and home management goals 1
• Definition, recognition, treatment, and prevention of relevant complications (e.g., hyperglycemia/hypoglycemia for diabetes patients) 1
• Information on consistent eating patterns and lifestyle modifications 1
• When and how to take medications, including proper administration techniques 1
• Recognition of signs requiring urgent medical attention 1

Assessment of Discharge Readiness

• Evaluation of mother-infant attachment and family dynamics (for obstetric patients) 2
• Screening for barriers to adequate follow-up care, including social determinants of health 2
• Assessment of family, environmental, and social risk factors that may require intervention 2
• Identification of need for home health referral or specialized outpatient programs 1

Common Pitfalls to Avoid

Communication Failures

• Only 42% of patients who failed to complete follow-up understood the reason for their referral, highlighting the critical importance of clear discharge communication 1
• Avoid assuming patients understand instructions without using teach-back methods to verify comprehension 1
• Do not rely solely on written instructions; counseling and telephone follow-up improve adherence to short-term regimens 1

Medication Management Errors

• Avoid rapid intensification of medication regimens in the hospital without considering that steady-state effects take 1-2 weeks for long-acting medications 1
• Do not discharge patients without ensuring prescriptions are filled and reviewed, as this increases risk of non-adherence 1

Follow-Up Scheduling

• Providing only verbal instructions to "follow up with your doctor" results in very low follow-up rates; scheduled appointments significantly improve compliance 1
• Educational interventions and mailed reminders alone have failed to improve follow-up rates without scheduled appointments 1

Transition Planning

• Avoid discharging patients without clear identification of the responsible outpatient provider 1
• Do not overlook the need for home health services or specialized outpatient programs for complex patients 1
• Ensure discharge summaries are transmitted promptly, as delays compromise continuity of care 1