Finally, we're paying attention to staying out of the hospital

It's just been lately that the American health system has really paid attention to readmission - that is, you have a stroke, stay in the hospital for likely a brief time, sent home with little or no follow-up, and you wind up back in the hospital.

Many reasons, but the bottom line is that for a long time, you were left to your own devices, with little or no instruction.

Now, the industry is paying attention to avoid that cycle. Check out the recent story how a stroke care transition program has cut readmission:

"A lot of stroke programs are doing follow-up phone calls to patients," Bushnell said, "but our data shows that phone calls alone are not good enough to reduce readmissions. It is really important for patients to be engaged in their own stroke recovery, and part of that involves coming to clinic and making sure they get all the services they need."

This model can help patients learn how to self-manage their stroke recovery and secondary prevention, Bushnell and colleagues said. "Beyond the initial assessment, a substantial portion of the calls and clinic visits are spent educating, coordinating care with referrals to therapy and community services, assuring that the services are actually received, addressing social needs, and handing off the care to the primary care provider."

"This is an important study given the need to define beneficial strategies to reduce readmissions following stroke," Robert D. Brown, Jr., MD, MPH, of the Mayo Clinic in Rochester, Minn., said in an email to MedPage Today.