Physicians who care for recently discharged patients have unique responsibilities, according to the American Medical Association. The physician group developed a list of recommendations to improve safety and reduce the rate of hospital readmissions for patients moving from a hospital stay back to their homes.

The responsibilities outpatient physicians should consider are:

  1. Assessment: Conduct a comprehensive, baseline assessment of the patient prior to admission, if possible, then update it after discharge.
  2. Goal-setting: Work with the patient to establish, document and update a set of goals and care decisions.
  3. Supporting self-management: Provide information and facilitate access to resources that can help the patient and caregivers safely manage the patient's conditions.
  4. Medication management: Communicate with the patient, pharmacy and other care team members to promote effective, safe medication use.
  5. Care coordination: Help to synchronize the efforts of all members of the care team to promote achievement of the patient's care goals.

In addition to these responsibilities, the AMA identified five principles to help guide ambulatory practices in completing them. They are:

  • Person-centered: Focus on the needs and goals of patients and their caregivers.
  • Collaborative: Take advantage of the complementary skills and talents of all team members.
  • Structured: Use clear and carefully planned protocols, forms and processes to help ensure comprehensive attention to core issues.
  • Iterative: Recognize the evolving nature of ambulatory care, repeating tasks over time as appropriate and make adjustments as the patient's care needs and goals evolve.
  • Flexible: Acknowledge the unique needs and circumstances of each individual and be prepared to pursue creative solutions to novel problems.

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