Coordinating Care after Hospital Discharges to Help Reduce the Chances of Readmissions

When our members receive inpatient hospital care, it’s important for hospital care teams to share information with primary care providers (PCPs) to coordinate care after discharge. Hospital discharge summaries can help our members transition from inpatient care, according to the American College of Physicians and others. Care coordination and planning can in turn help reduce the chances of hospital readmissions, according to the National Committee for Quality Assurance (NCQA).

If you provide care to our members during or after a hospital discharge, consider the following tips to support care coordination.

For Hospital Care Teams

  • Give PCPs timely access to hospital discharge summaries. Discharge summaries should include information on:
    • Course of treatment
    • Diagnostic test results
    • Follow-up plans
    • Diagnostic test results pending at discharge
    • Discharge medications with reasons for changes and most commonly known side effects

For Primary Care Providers

  • Obtain the member’s hospital discharge summary and schedule a timely follow-up visit to discuss discharge instructions. Consider telehealth services when available and appropriate.
  • Perform a medication reconciliation to compare hospital medication orders to the medications the member has been taking. This is done to prevent drug interactions, duplications or other errors.
  • Talk with our members about unique risks and barriers they may face that might have played a role in hospitalization. Our Health Equity and Social Determinants of Health page has information that may be helpful.

How We Can Help

  • Let our members know we offer help and information in their language at no cost. To speak to an interpreter, members may call the customer service number on their member ID card.
  • We have the potential to provide Medicaid members with free non-emergency transportation services, as well as mileage reimbursement.
  • Blue Cross and Blue Shield Federal Employee Program® (FEP®) members may call 1-800-462-3275 to connect with a case manager after discharge.
  • Blue Cross Community CentennialSM Plan members may call 1-877-232-5518 to speak with care coordinators.

Tracking our members’ progress

We track Plan All-Cause Admissions, which is a Healthcare Effectiveness Data and Information Set (HEDIS®) measure from NCQA. This captures the number of acute inpatient and observation stays during a measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days. The measure applies to Medicare Advantage members ages 18 and older, and to other members ages 18 to 64.

As part of the Blue Cross and Blue Shield of New Mexico (BCBSNM) provider satisfaction survey, we also track responses from PCPs and specialists about the timely sharing of hospital discharge summaries. The survey results help us identify opportunities to improve coordination of care.

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. The fact that a service or treatment is described in this material, is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.