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Discharge Planning and Transitions of Care

Sarah A. Bajorek, PharmD, BCACP; Vanessa McElroy, RN, BSN, PHN, ACM-RN IQCI | March 25, 2020
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Transitions of care refer to the movement of patients between different healthcare settings such as from an ambulance to the emergency department, an intensive care unit to a medical ward, and the hospital to home. The transition from hospital to home can be challenging as patients and families become responsible for care coordination. Hospital discharges are complicated and often lack standardization. Patients receive an onslaught of new information, medications, and follow-up tasks such as scheduling appointments with primary care providers.

Suboptimal transitions of care increase the risk of readmissions and adverse drug events after discharge.1 The discharge process can be influenced by characteristics and activities of the health system, patient, and clinician.2 Discharge instructions may differ between providers, or may not be tailored to a patient’s level of health literacy or current health status.3 Prior studies have shown that an early discharge preparation process can significantly decrease hospital length of stay (LOS), readmission risk, and mortality risk.4

As such, discharge planning should begin as soon as possible. However, studies show it is often difficult to predict the day of discharge accurately,5 which may contribute to the practice of communicating important information on the day of discharge6 and patients and caregivers feeling that the discharge process is rushed. Healthcare professionals may overestimate the time spent on providing discharge instructions as well as their patients’ understanding.7 In addition, healthcare professionals and patients use different wording to describe health-related terms.6 All of these factors can play a role in the patient’s ability to state their diagnosis, medication name, indication, or side effects.8 Furthermore, discharge instructions oftentimes instruct patients or caregivers to schedule follow-up appointments with their primary care provider or specialty providers after discharge. However, up to half of the patients instructed to make the appointment may not understand the reasons or mechanism for doing so, and therefore do not make the appointment.6

Identifying Risk Factors for Poor Transitions

In one seminal study, patients who understood their post-discharge plan had a lower rate of subsequent hospital utilization (ED visits or hospitalizations) than those who did not.9 Challenges to understanding discharge instructions include patients’ lack of physical or emotional readiness to learn and the fact that family members or patient caregivers may not be consistently involved with the educational and discharge planning efforts. Discharge instructions may be unclear and may not be tailored to patient’s individual learning style, social determinants, or health literacy needs. Furthermore, education provided from different healthcare providers may include conflicting or confusing information. Discharge information should be written clearly in patient-friendly terminology and be tailored to the patient’s learning style, social determinants, and health literacy needs.10

Assessment of patient and caregiver concerns and risk factors associated with nonadherence should be addressed throughout the hospitalization, including lack of engagement, poor continuity of care, and complex treatment regimens.11  Oftentimes, patients may be non-adherent because of poor understanding or confusion about needed care, transportation, and how to schedule appointments.12  Lack of follow-up appointment coordination prior to discharge results in patient and family caregivers not knowing who and when to follow up with when there are multiple providers.3 In addition, there can be a lack of clear communication of the post-discharge care plan between the physician and the home health care team following the home health orders.

A systematic review of nine studies grouped factors for medication nonadherence into patient-related factors (i.e. disease-state knowledge, health literacy, cognitive function), drug-related factors (i.e. adverse effects, polypharmacy), patient-provider relationship, and logistical factors (i.e. transportation and medication access).14 Proactively assessing these factors may streamline the discharge process.

Improvements in Discharge Planning and Transitions of Care

Discharge education should be provided throughout the hospitalization and then understanding confirmed on the day of discharge. There are tools available to help facilitate discharge education such as “teach-back” which assesses the key learner’s understanding of the discharge instructions.15  Another strategy is to incorporate a discharge checklist. Some studies demonstrate the value of discharge checklists to document required components for a safe discharge.16,17  One study found that 1 in 10 discharges include errors in discharge instructions, incorrect discharge medications, or a good catch and approximately a third of patients may need additional education prior to discharge.18 While checklists may be helpful, they do not replace appropriate training or clinical competence.19  Resources such as the AHRQ Re-Engineered Discharge (RED) Toolkit can help provide evidence-based training for staff as well as outline processes to improve the discharge process and reduce readmissions.9

Nurses play an integral role in the discharge process by coordinating care and providing timely communication with key stakeholders including families and community providers to ensure smooth transitions of care.  Additionally, pharmacists can play a crucial role in medication safety during transitions of care through medication reconciliation and discharge education.20 Pharmacists can ensure patients understand their medications and can obtain them after leaving the hospital. Furthermore, since the majority of post-discharge adverse events involve medications, pharmacists can assist with post-discharge telephone follow-up to check in with patients and proactively address any medication related issues.21

Effective discharge planning can help reduce medical errors during transitions of care, which is known to be a time during which patients are particularly vulnerable. Planning for discharge should involve the patient and caregiver and begin as soon as possible during the hospitalization. The IDEAL discharge planning strategy is one approach emphasizing patient and family engagement in discharge planning and discharge education.22 Additionally, AHRQ houses a library of evidence-based resources and tools to improve the discharge process and care transitions.23

Sarah A. Bajorek, PharmD, BCACP
Pharmacy Supervisor, Transitions of Care and Medication Reconciliation
University of California, Davis Health

Vanessa McElroy, RN, BSN, PHN, ACM-RN IQCI
Director, Care Transition Management
University of California, Davis Health


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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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