Penn Medicine


Re-Designing Discharge to Reduce Readmissions


Congestive Heart Failure (CHF) patients face issues of access and behavioral barriers that put them at high risk for readmission and other adverse health outcomes.

We observed staff on five in-patient floors at the Hospital of the University of Pennsylvania (HUPand shadowed more than 20 patients in the hospital and at home to learn about the challenges that CHF patients face after they’ve been discharged.

During observation we found that many patients did not reference the care instructions and supplemental literature provided by hospital staff at discharge.  Instead, we found that many patients had developed their own systems and tools to help manage their care after returning home.

Our main takeaway was that the current discharge process aims to educate the patient right before they leave the hospital, at a time when they and their loved ones are in a state of high anxiety.  


To test our assumption that providing information to patients when they need it would increase utilization, we designed a mock service called “HealthyTrack.”

While patients were still in the hospital, we worked to educate them about the symptoms they should look out for, and the actions they should take when those symptoms occur.  Information about each symptom was recorded on an individual card. 

Before leaving the hospital, patients were given the set of symptom cards on a ring with instructions to review them daily and report their health status via the HealthyTrack service line.  The service line was a fake back-end created by our team- a Google Voice account that went straight to our personal mobile phones. 


We engaged eight patients in the experiment over a two week period.  One patient declined to participate, two were discharged to a skilled nursing facility and therefore did not meet our criteria, two were discharged before we could fully enroll them in the service, and three were successfully enrolled.  The patients were deeply engaged in the course of their care while in the hospital.  Unfortunately, soon after the patients were discharged, the level of engagement decreased and patient opted out.

This experiment highlighted barriers to long-term engagement with low SES populations and challenged our team to consider customized patient education strategies for different populations for future interventions. 


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