“The doctor just wrote your discharge orders — you’re ready to leave the hospital and go home.”
That’s great news 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. Or maybe you were discharged from the ER after receiving pain control, but you’re concerned that a diagnosis wasn’t thoroughly investigated.
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 yourself. 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. However, 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.
[SEE: 10 Items to Pack in Your Hospital Bag.]
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. It started with her work in the cardiovascular unit there, coordinating a program for patients with heart failure — the condition with one of the highest 30-day rehospitalization rates in the U.S, accounting for one in four readmissions.
Through thorough patient education, discharge planning and advocacy, follow-up calls, and support roles for the patient, family and caregiver, the evidence-based program led to reduced readmissions for these patients in the UCSF system, Brinker reports.
Now, Brinker says, 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, such as 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 and her colleagues 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.”
[RANKINGS: Best Hospitals]
Expectations Then and Now
This isn’t your parents’ hospital experience, and it’s certainly not that of your grandparents. If your expectations are drawn from past recollections of lengthy hospital stays, they won’t sync with today’s reality of rapid-as-possible discharges.
“Some of the best work for preparing patients for discharge is focused on the conversation with patients and families and launching into those conversations early on,” says Dr. Rachel Thompson, the chief medical officer at Snoqualmie Valley Health in Snoqualmie, Washington. “One of the biggest challenges is when a patient’s expectation doesn’t match with what’s in the provider and caregiver minds about what the discharge plan 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. So, you can see where expectations can become mismatched.”
Communication and readiness are improving with targeted efforts in areas such as surgery, Thompson adds. 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, “when we all have the same expectations, when we communicate well and early, we are all on the same page when it comes time to go home.”
[See: 11 Pre-Surgery Tips to Boost Recovery.]
Keys to a Safe Hospital Discharge
In order to prevent an unsafe discharge from the hospital, these issues should all be addressed prior to your returning home or being admitted to another type of facility:
— 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 review 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 no one can retain all that information.” Discharge information should be organized, detailed and individualized. “With electronic health records, some of the discharge paperwork has become so much more refined,” she adds.
— 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 patients to be aware of key symptoms to watch for, such as excessive bleeding from a surgical site, leg pain, or warmth or swelling after prolonged bed rest. By knowing what to look for, they can alert their health care provider or seek emergency treatment if needed.
Once the above issues are sorted, a hospital discharge should be smooth sailing. If you’re trying to get discharged from the hospital quickly, working on the above items during the course of your stay will be your best bet. Hospital team members such as nurses and social workers also work with patients to get a sense of barriers. This way, they can meet the needs of their patients and improve safe discharges.
“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 to providers the need-to-know concepts that they were recently taught. 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
Ironically, hospitals can’t force you to stay against your will, and the process of leaving early against medical advice, or AMA, is much simpler than the process of refusing a too-soon discharge. And unfortunately, the discharge-to-home experience is far from ideal in many hospitals.
Request to speak to the doctor if an 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 a medical injury.
“It’s probably the first thing you should do,” says Haskell, who was drawn to patient advocacy after her 15-year-old son, Lewis, 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, such as 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 do have the right to refuse discharge from the hospital. Here are the steps you can take 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 adds, “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,” that should help get someone to stop and listen in the majority of systems, Thompson notes.
Tools for a Good Discharge
No matter how long patients have been in the hospital, it’s always a flurry of activity to get the patient discharged, says Dr. Catherine MacLean, the chief value medical officer at Hospital for Special Surgery in New York City. “It’s complicated,” she adds. “There are a lot of process steps that have to happen.”
MacLean points to the Re-Engineered Discharge Toolkit, a discharge-improvement program from the Agency for Healthcare Research and Quality as one measure to ensure safe discharges. 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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Don’t Let a Premature Discharge Put Your Health at Risk originally appeared on usnews.com
Update 03/02/23: This story was previously published at an earlier date and has been updated with new information.