Rethinking Discharge Communication

by Mary Kay Thalken, RN, MBA on Nov 4, 2016

October 31, 2016 - Advance Healthcare Network for Nurses

Six Ways Nurses Create a Smoother Transition to the Next Phase of Care

By Mary Kay Thalken, RN, MBA, Chief Clinical Officer of Ensocare

Communication errors are the number one cause of adverse events in hospitals, according to the Joint Commission, and times of transition-including patient handoffs, transfers and discharges-are especially risky. In the ramp up to patient discharge, for example, nurses, case workers and care managers are busy with a plethora of diverse tasks that pull them in many different directions. This creates an environment where communication exchanges are, at best, fragmented. It also sets the stage for potential communication breakdowns between hospitals and post-discharge providers, which can, in turn, lead to lapses in care or duplicative care, or medication errors.

Contemplating what to do after discharge from the hospital can be daunting for both patients and families. If leaving the hospital doesn't equate to going home, decisions surrounding post-acute facilities for continuing care must often be made quickly, and without a great deal of supporting information. This can cause both the patient, and the receiving facility, to be ill-prepared for what comes next.

Discharge Chaos

Consider the case of a patient who was discharged from a hospital but needed to be placed in a skilled nursing facility. The patient's family selected the facility one day and the individual showed up for care the next. The quick transfer did not lend itself to effective information exchange, transfer of pertinent clinical information, or preparation for this patient's unique medical needs.

With her medical record literally on her lap, this patient arrived in need of care. There was no care plan or physician orders and the facility was not prepared to begin the therapy she needed right away. Care was delayed and some medication doses missed. Not only did the patient have a rocky start -which was stressful and could have been avoided-she eventually made a return trip to the hospital due in part to the fragmented care she received during the post-acute transition.

There are far better ways to safely move patients to the next level of care and in response, many hospitals and health systems have begun revamping their discharge communication strategies. The following tactics are some of the ways that care transitions are being handled more effectively to enable comprehensive and consistent communication before, during and after the patient leaves the hospital.

Six Steps for Smoother Communications

1.  Start discharge planning early
Acute care providers generally have a good idea very soon after patient admission whether the individual will need post-acute care and what that care will entail. Organizations can take advantage of this insight and begin the discharge planning process as early as possible. This may involve reaching out to potential organizations right away and setting patient and family expectations upfront. By getting a jump start on discharge planning, organizations can be more careful and deliberate instead of rushing the process.

2.   Consider the patient's clinical and psychosocial needs
Not every patient will require the same type and level of care when they leave the hospital. Some patients may need occupational therapy while others may require a special kind of treatment, such as dialysis. People will also have different psychosocial preferences as well. What one patient considers to is a calming environment, for instance, may be too quiet for someone else.

To ensure patients are matched with the most appropriate facilities, hospitals must consider the individuals' specific clinical and psychosocial needs when starting to search for options. Technology can be helpful with this process. Organizations that use automated discharge planning software can generate a thorough, targeted list of facilities that closely match a patient's unique requirements. Going a step further, hospitals can reach out via email to all potential facilities and obtain responses within hours as to whether or not the patient can be accepted. The hospital can then provide the patient and family with a well-vetted list.

3.   Talk through the possibilities
Once a hospital has generated a potential list of facilities, a care manager should have compassionate and informative conversations with patients and families about their options. In some cases, a care manager may be able to show the patient virtual tours of various facilities, so they can truly get a sense of whether they might be comfortable there. During these conversations, the provider may also learn about certain patient and family concerns and share those with the receiving facility, providing an even fuller picture of the patient before transfer. 

4.  Send the most relevant clinical information
Once a patient and family decide on a location, it is essential to have open and effective information exchange with that entity. This communication should occur before the patient enters the post-acute facility, allowing the organization to fill any medication or therapy orders by the time the patient arrives onsite.

When selecting the information to share, organizations should refrain from sending the entire medical record as this frequently includes a level of detail and history that is unmanageable and also unnecessary. It is more useful to send a brief description of the most current and pertinent information.

Technology can support prompt and appropriate information exchange. Think about the earlier example. What if the organization had used an automated solution that lets them directly share key information from the patient's EHR with the receiving facility's system as soon as the post-acute care decision was made? The receiving provider could have set up treatment therapies and have all the proper orders ready, avoiding care delays, medication omissions and preventable hospital readmissions. 

5.   Focus on patients who are high-risk for returning to the hospital
Although organizations should communicate clearly and compassionately with all patients during discharge, they should be especially mindful of those individuals who are at high risk for readmission. A high-risk patient may be slow to get better or not respond well to treatment. He or she may have a lack of family support or a history of treatment non-compliance.  An organization may want to employ software tools that identify these individuals prior to discharge, allowing the organization to intervene with proactive care interventions and be especially vigilant about communication to prevent a return visit to the hospital.

 6.  A systematic approach is the answer
Although there are many moving parts during discharge, particularly for complex patients who have multiple clinical and psychosocial needs, organizations that implement defined processes and systems that make communication more intentional and complete can reduce the risk of adverse events and ensure positive patient outcomes and satisfaction. This will become increasingly important as organizations start to comply with new initiatives-such as the Comprehensive Joint Replacement (CJR) Model-which requires cross-continuum communication and collaboration. Technology is a key factor in enabling better interactions between settings, and organizations seeking solutions that foster standardization, timeliness and focused information-sharing can take a giant step toward safe and reliable patient care.

It all comes down to well-coordinated, well-planned and well-communicated transitions of care. With the support of technology solutions designed to facilitate improved communication, share relevant patient information and include patients/families in the decision-making processes, outcomes can be impacted in a positive way.

View the full article in Advance Health Network for Nurses here.

Meet the Author

Thalken brings more than 30 years of experience in health-care leadership to our company. Prior to joining the company, she served as Enterprise Vice President for Care Logistics in Atlanta, Ga. She has held executive leadership positions at hospitals in Nebraska and Iowa, including the position of System Quality Executive for Alegent Health. Thalken has presented on the topics of improving quality, patient flow and throughput at various industry conferences and webinars. Thalken holds an MBA from the University of Nebraska at Omaha. She is a member of the American College of Healthcare Executives, American Organization of Nurse Executives and American Case Management Association.


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