Table 5.

Interventions That May Have Prevented Hospital Revisits

Possible interventions	Mean score*	Potentially preventive interventions†
		n, not pandemic related	n, pandemic related	n, total (% cases, N = 20)‡
Improved self-management plan at discharge (for example, discharge coach, discharge information in the patient's own language, increased engagement of patient/caregiver to ensure understanding of the discharge plan)	3.5	10	3	13 (65.0)
Improved clarity, timeliness. or availability of information provided at discharge (for example, timely communication with postdischarge providers)	2.2	7	2	9 (45.0)
More complete communication of information (for example, improved discharge documentation)	2.2	5	2	7 (35.0)
Improved physician or care team recognition of or attention to patient symptoms (such as pain, dyspnea, depression, anxiety)	1.8	4	2	6 (30.0)
Improved coordination between inpatient and outpatient providers (for example, with primary care office, shared medical records, communication that includes all team members, provider continuity)	1.9	4	2	6 (30.0)
Improved discharge planning (for example, faster follow-up with ambulatory providers, appointments made at times patient could attend)	1.9	4	2	6 (30.0)
Improved attention to medication safety (for example, medication list with pictures, filling prescriptions prior to discharge or having them delivered to home, improved medication reconciliation)	2.1	4	1	5 (25.0)
Provision of resources to manage care and symptoms after discharge (for example, follow-up phone call, nurse home visit, intensive disease management system, postdischarge ongoing case management, access to index hospital team for questions/concerns after discharge)	1.8	4	1	5 (25.0)
Greater engagement of home and community supports (for example, nonclinical social support assistance such as adult day care, meals on wheels)	1.4	2	0	2 (10.0)
Financial, insurance, or transportation assistance	1	0	0	0 (0)
Improved advance care planning (for example, establishment of health care proxy, discussion of goals of care, palliative care consultation, hospice services)	1	0	0	0 (0)

^⁎For each preventable revisit, each intervention was evaluated and a score of 1 to 6 was assigned, where “1” represented no probability of preventing the revisit, and “6” represented nearly certain probability of preventing the revisit.

^†An intervention was considered potentially preventive if it received a score of 2–6. It was considered “pandemic-related” if it was associated with a revisit with contributing factors directly related to the pandemic.

^‡Cases could have more than one intervention, so percentages total more than 100.