“The doctor just wrote your discharge orders — you’re ready to leave the hospital and go home.” That’s great to hear if you’re actually prepared.
However, what if you’re stunned at the notion that you’re well enough, or well-prepared enough, to leave? You had surgery yesterday and there’s no one to change your bandage at home. You’re confused about which medications to take, or why. You don’t have a follow-up appointment, you’re not sure who to call if problems arise and you feel sick, weak and helpless.
To you and your family members, it seems obvious that you’re not physically or logistically ready to head for the hospital exit and fend for yourselves. But try telling that to the medical team on morning rounds who matter-of-factly announced your discharge and said goodbye: They’ve already walked off the unit.
Pressure is on for hospitals to discharge patients as soon as possible. Insurance won’t cover inpatient stays indefinitely and other, just-as-sick patients are waiting to be admitted. Yet existing patients who leave when they’re too ill, or when they don’t understand the next steps in their care, do worse and are more likely to return to the emergency room or be readmitted within the next 30 days — which insurers also frown on.
Health care agencies, hospital-based clinicians and patient advocacy groups are making efforts to improve the discharge process so patients can do better as they recover in the community. Learn what’s being done to make discharges work and how patients and families can speak up and have their concerns heard in time.
Ideal Hospital Discharge
Optimizing hospital discharge to improve patient care has been an ongoing mission for Eileen Brinker, a transitional care nurse at UCSF Health, in San Francisco, California. It started with her work on the cardiovascular unit there, coordinating a program for patients with heart failure — the condition with the highest 30-day rehospitalization rate in the U.S, accounting for one in four readmissions.
Through thorough patient education, follow-up calls, discharge planning and advocacy and support roles for the patient, family and caregiver, the evidence-based program led to reduced readmissions for these patients in the UCSF system.
Now, UCSF Health is participating in research to improve transitions among health care settings. Their randomized controlled trial replicates what’s known as the transitional care model. In this model, an advanced practice nurse, like a nurse practitioner, meets and follows a patient and family from their inpatient hospital stay through their outpatient experience for a few weeks to months after discharge. The program is particularly geared toward older adults with complex health and social needs.
“We realize the fragility and complexity of being in the hospital — all the information you receive, decisions and planning when you aren’t feeling well — and then being discharged and having to go home and do it on your own,” Brinker says. “There is an immense amount of information and tasks to do about your new medical condition.”
In the transitional care model, discharged patients experience unparalleled continuity of care when they leave the hospital. “The same nurse visits older adults within 24 hours, accompanies them to their first physician visit and maintains regular contact through home visits — in-person and telephonic — over three months to monitor patient’s symptoms, ensure patients adhere to their care plans and position patients and family caregivers to manage future health needs in a manner consistent with their goals and preferences,” Brinker explains.
Focusing more attention on hospital discharge and the aftermath means better outcomes for seriously ill patients, according to results from studies like these:
— Timely home health nursing visits and outpatient follow-up significantly reduced early readmissions for patients with heart failure, in a study published in the journal Health Services Research.
— Among nearly 180,000 Medicare patients with severe sepsis and multiple medical conditions, early home-health nursing combined with early physician follow-up significantly reduced readmissions, in a study published in the journal Medical Care.
Earlier in her career at the bedside, Brinker says, she and her colleagues had realized there was a disconnect between their discharge hopes for patients and what might actually happen. “We would get them set up on a wing and a prayer,” she recalls. “You would hope that all your referrals would happen, that the home health nurse actually comes and that patients get the medications you prescribe to them.”
The uncertainty was frustrating. “There was no kind of loop-closing to know: Did that all happen?” Brinker says. “And if not, who do they call? Who does the pharmacy call? Do they call the case manager if they find out the home health nurse never came, because there was an insurance issue or authorization issue that is way beyond what the patient can see?”
Brinker is encouraged by the strides since made in hospital-to-home transitions. “I’ve worked in inpatient care for 16 years,” she says. “And this is amazing, because finally we’re connecting inpatient and outpatient services.”
Expectations Then & Now
This isn’t your parents’ hospital experience, and certainly not that of your grandparents. If your expectations are drawn from past recollections of lengthy hospital stays, that won’t sync with today’s reality of rapid-as-possible discharges.
“Some of the best work for preparing patients is really about transparency, and the conversation and launching into those conversations early on,” says Dr. Rachel Thompson, the chief medical officer at Snoqualmie Valley Health District in Snoqualmie, Washington. “One of the biggest challenges is that what we have currently doesn’t match with a lot of what’s in people’s minds about what should be.”
In prior generations, it went something like, “Mom was in the hospital with pneumonia for a month,” says Thompson, who is also president of the Society of Hospital Medicine’s board of directors. “Now, we treat pneumonia at home.”
Communication and readiness are improving in areas such as surgery, Thompson says. Enhanced recovery after surgery, which involves postoperative protocols to speed up and improve the recovery process, includes talking to patients and families about where they are on the recovery trajectory to keep them in the loop and reduce their anxiety.
In general, Thompson says, “If people have the same expectations, if we had done a better job communicating early, we would have been on the same page when it came time to go home.”
Keys to a Safe Hospital Discharge
Before you move on from the hospital, whether to home or another type of facility, these issues should all be addressed:
— Medications. Can you tolerate newly ordered medications? Are they helping? For each new drug, what is the dose and schedule once you get home? “Some hospitals have a pharmacist come and go over all the medications,” Thompson says. “The pharmacist should say: Hey, here’s what you were taking before, here’s what you’re on now and these are the differences. These are the ones you should stop. These are the ones you should start.”
— Caregiving needs. If you’ll be incapacitated after ankle surgery, for instance, is there someone to help you at home? If your parent is being discharged but they’re having problems with functional or cognitive changes, who will help keep them safe? Organizing at-home caregiving is a priority.
— Bedside education. Nurses provide ongoing education to patients throughout their stay, not just at the point of discharge. Patients learn about their condition and treatments in such a way that they can gradually absorb information.
— User-friendly discharge information. Providing a packet of information that’s “super-clear” is imperative for patients, Thompson says, “because you can’t retain it all.” Information should be organized, detailed and individualized. “With electronic health records, some of the discharge paperwork has become so much more refined,” she says.
— Appropriate referrals. Patients need to know who will continue their care in the community. That can include primary care providers, specialists, physical and occupational therapists and more. Patients and families need those contact names and numbers.
— Symptoms to monitor. It’s important for discharged patient to be aware of key symptoms to watch for, such as excessive bleeding from a surgical site, or leg pain, warmth or swelling after prolonged bedrest. By knowing what to look for, they can alert their health care provider or seek emergency treatment if needed.
Hospital team members like nurses and social workers also try to get a sense of barriers to meeting these needs so they can be overcome.
“We’re also looking at the social support, starting on admission,” Brinker says. “What’s the patient’s cognitive impairment, if any, their functional status, availability of family and caregiving at home, ability to take their medications, organize them and take them appropriately and get to appointments?” It’s about matching patients to services, specialists and programs — like home-based primary care — that could be a perfect fit.
When patients sometimes wonder why clinicians ask so many questions during hospitalization — that’s why, Brinker says.
Teach-back by patients is another way to assess and improve their readiness for discharge. In this technique, patients or caregivers explain need-to-know concepts that they were recently taught back to providers in their own words. You can initiate teach-back as a patient by asking clinicians like doctors or nurses to validate your understanding of your condition and care requirements.
When You Don’t Feel Ready
Unfortunately, the discharge-to-home experience is far from ideal in many hospitals.
Demand to speak to the doctor if immediate discharge isn’t right for you (or a family member) as the patient, says Helen Haskell, president of Mothers Against Medical Error, a South Carolina-based group dedicated to improving patient safety and providing support for patients who have experienced medical injury.
“It’s probably the first thing you should do,” says Haskell, who was drawn to patient advocacy after the death of her 15-year-old son Lewis, who died in the hospital following routine surgery. If the doctor isn’t available, she adds, “demand that they contact the doctor for you.”
Haskell also recommends getting in touch with Medicare or your insurance company, whichever applies, with premature discharge concerns.
If you’re a patient getting Medicare services from a hospital (or another health care setting like a skilled nursing facility), you can ask for a fast appeal to delay your discharge. Your provider should then give you a “Notice of Medicare Non-Coverage” that tells you how to request the appeal. An independent reviewer will then decide whether your Medicare-covered services can continue.
If You Feel You’re Being Discharged Too Soon
You can take steps if the hospital tries to show you the exit when you don’t feel safe or prepared:
— Speak up. “If you have concerns, if you don’t feel heard, advocate until you find the right person to listen,” Brinker says. “We want you to be heard, we want to listen to you. You have a voice in this process.”
— Go up the chain of command. Make the bedside nurse aware of your concerns about discharge. If that doesn’t help, ask to speak with the charge nurse, nurse manager or director of nursing. Similarly, if a medical resident or physician assistant brushes you off, speak with the attending physician.
— Ask Medicare to delay your discharge. You can also start the process by calling 800-633-4227 (800-MEDICARE). Look through the “Medicare Appeals” booklet from the Centers for Medicare & Medicaid Services to learn more.
— Enlist the hospital’s patient advocate. Most hospitals have personnel called patient advocates or patient representatives to help patients resolve their concerns. You can request a visit from the patient advocate or contact them directly for a variety of issues including possibly being discharged too soon.
— Use language that providers connect with. Phrases such as ‘I don’t feel good about this’ or ‘I don’t feel comfortable’ tie into safety language that hospital staff members are trained to think in, Thompson says. “That antenna just pops right up,” she says. “Because we’re all cued in to: We want to keep patients safe.” So if you as a family member say: ‘I don’t feel safe taking care of Mom at home,’ or as the patient: ‘This next step is not feeling safe to me,’ Thompson says, “That should help get someone to stop and listen in the vast majority of systems.”
Tools for a Good Discharge
No matter how long patients have been in the hospital, it’s always a flurry to get out, says Dr. Catherine MacLean, the chief value medical officer at the Hospital for Special Surgery in New York City. “It’s complicated,” says MacLean, who points to research that looked behind the scenes at everything that must be completed before clinicians can discharge a patient. “There are a lot of process steps that have to happen,” she says.
MacLean points to the Re-Engineered Discharge (RED) Toolkit, a discharge-improvement program from the Agency for Healthcare Research and Quality. Participating hospitals use the patient-centered, standardized approach to discharge planning to improve patient preparedness for self-care and reduce preventable hospital readmissions.
You can download a patient booklet called “Taking Care of Myself: A Guide for When I Leave the Hospital,” based on the RED toolkit, from the AHRQ website. The guide includes comprehensive checklists and forms for you to track details on medications, follow-up appointments, contact numbers and other information to discuss with the hospital staff before discharge. You can then refer to and share the guide with family members or other caregivers at home, as well as bring it to doctors’ appointments outside the hospital to update them on your care.
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What to Do if the Hospital Is Discharging You Too Soon originally appeared on usnews.com
Correction 05/19/22: A previous version of this story misstated a funding source for UCSF Health’s research to improve transitions among health care settings.
Update 07/06/22: This story was previously published at an earlier date and has been updated with new information.