“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?
This exact scenario happened to a client of Dr. Gerda Maissel, a board-certified physician in physical medicine and rehabilitation and patient advocacy in New York. Maissel is also the president of My MD Advisor, a patient advocate service.
“My client called me, panicked,” Maissel recalls. Her client was admitted to the hospital for back pain, and happened to be diabetic. While in the hospital, her blood sugar was consistently high, so her hospital doctors started her on insulin for the first time. Once her back pain was better, the hospitalist wrote her discharge orders to go home. The hospitalist also told her she would need to continue the insulin at home by administering it to herself every day twice a day, based on varying blood sugar readings.
This concerned Maissel as her client’s advocate.??
“She had never given herself insulin, and the idea scared her. She lived alone and was afraid of needles. She was afraid she’d give herself the wrong dose and pass out,” Maissel recalls. “I told her to appeal her discharge.”
Read on to learn more about what an unsafe discharge from hospital is, and how to prevent scenarios like these.
Why Do Hospitals Discharge Too Soon?
The pressure is on for hospitals to discharge patients as soon as possible, for a few reasons:
— Insurance reimbursement. Insurance doesn’t cover inpatient stays indefinitely. In order for hospitals to receive reliable insurance reimbursement, they make sure patients don’t stay longer than necessary. But sometimes, this goes too far and patients are discharged too soon. However, when patients aren’t ready to go home, they’re more likely to be readmitted within the next 30 days — which insurers also frown on.
— Short-staffing. Short-staffing can push early discharges in an effort to relieve pressure off the floor staff. “The problem is due to poor staffing and heavy pressure to discharge quickly from hospital administration. Few care managers or bedside nurses have time or the courage to say ‘stop,'” says Teri Dreher Frykenberg, a Libertyville, Illinois-based nurse and the CEO and founder of NShore Patient Advocates.
— Hospital occupancy limitations. There are just-as-sick patients waiting to be admitted who need beds too. Unfortunately, this can push patients out who are improving, but not well enough to go home yet.
— Hospital initiatives. Some hospitals have goals and initiatives for how many discharges they perform. Or they try to arrange discharges within a specific time window, like before the night shift clocks in.
[SEE: 10 Items to Pack in Your Hospital Bag.]
How Do I Know I’m Ready to Be Discharged From the Hospital?
To prevent an unsafe discharge from the hospital, these issues should all be addressed prior to 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? Has a pharmacist made sure you understand which medications you need to start and stop?
— Caregiving needs. If you’ll be incapacitated after ankle surgery, for instance, is someone available 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. Every hospital should provide you with a discharge packet, sometimes also called an “After Visit Summary.” The AVS will contain some boilerplate instructions based on your admission diagnosis, but there should also be some personalization too. Make sure your discharge packet includes your follow-up appointment, as well as any medication or treatment changes.
— 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 to know who to follow up with and any relevant contact information.
— 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.
— Social needs. “We’re also looking at the social support, starting on admission,” says Eileen Brinker, a transitional care nurse at UCSF Health in San Francisco. “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.
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 these 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.
[How to Advocate for an Older Loved One in the ER or Hospital]
What Is an Ideal Hospital Discharge?
There are a few hallmarks of an ideal hospital discharge, including:
— Care coordination
— Proper transitional care
— Thorough discharge education
— Utilizing discharge resources
1. Care coordination
In Maissel’s case, she turned a discharge nightmare into a success.
After the patient expressed concern about going home on a new insulin regimen, the discharge planner came by. Maissel worked with the discharge planner to ensure a diabetic educator would teach her client how to administer insulin safely. Maissel also made sure her client had the means to pick up the new insulin prescriptions and that someone was at home with her client for at least a few days until she felt safe.
Streamlining services and coordinating providers’ efforts is essential to ensuring a smooth hospital discharge and supporting patients in a successful recovery.
[See: 11 Pre-Surgery Tips to Boost Recovery.]
2. Proper transitional care
Focusing more attention on hospital discharge and the aftermath means better outcomes for seriously ill patients, according to results from studies, including:
— Timely home health nursing visits and outpatient follow-up significantly reduced early readmissions for patients with heart failure, in a 2017 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 2019 study published in the journal Medical Care.
Optimizing hospital discharge to improve patient care has been an ongoing mission for Brinker.
It started with her work in the cardiovascular unit at UCSF, 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 1 in 4 readmissions.
Between 2020 and 2023, UCSF Health participated in research to improve transitions among health care settings. Their randomized, controlled trial replicated 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.
The evidence-based program led to reduced readmissions for these patients in the UCSF system, Brinker reports.
3. Thorough discharge education
Having a clinician sit down with you before you leave the hospital to discuss your concerns and answer questions is essential. If you have to continue any treatments at home, like Maissel’s client had to self-administer insulin, teach-back is a great way to help you feel ready 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. For example, you’d give yourself your first insulin shot with a nurse or diabetes educator watching you.
4. Utilizing discharge resources
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. Hospitals can 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, “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.
What If I’m Being Discharged From the Hospital Too Soon?
Can a hospital force you to leave? No. 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:
1. 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.”
2. Go up the chain of command. If an immediate discharge isn’t right for you (or a family member) as the patient, speak to a doctor, 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.”
3. Ask your insurance company to delay your discharge. If you’re on Medicare, you can also start the process by calling 1-800-633-4227 (1-800-MEDICARE). Look through the “Medicare Appeals” booklet from the Centers for Medicare & Medicaid Services to learn more. If you have private insurance, call your member services line and let them know you have premature discharge concerns. Discharging too soon could cause an unnecessary readmission later on, which is costly for insurance companies.
4. 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.
5. Ask for a fast appeal to delay your discharge. 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.
6. Use language that providers connect with. Health care providers are taught to respond to “CUS” language, a communication tool outlined by the AHRQ. To use CUS language, state your ‘concern,’ state why you are ‘uncomfortable’ and, if it’s not resolved, state that this discharge is a ‘safety’ issue. Your provider should immediately tune into your distress.
The Bottom Line
Both staying in and leaving the hospital can be overwhelming.
“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.”
Make sure you understand the hallmarks of a safe hospital discharge, where you understand your diagnosis, new treatments, medication changes and what symptoms to look out for. If you don’t feel safe to leave, don’t hesitate to speak out to your doctor, contact a patient advocate or even call your insurance company.
Looking for a hospital you can trust with your care and your discharge? Look at a compiled list of U.S. News & World Report Best Hospitals.
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Don’t Let a Premature Discharge Put Your Health at Risk originally appeared on usnews.com
Update 08/28/24: This story was previously published at an earlier date and has been updated with new information.
