How You Can Exit the Hospital Successfully
Upon being discharged from the
hospital, many patients believe that the toughest part of their
recovery is behind them. However, in reality, it usually means the
beginning of a new routine in a person’s health care – one that
involves more organization, effort, and awareness. A patient’s
discharge from the hospital is a critical transition point in the
“continuum of care” and is often cited as the ultimate reason for
hospital readmission.
About 25% of hospitalized patients experience an adverse event when
they transfer from hospital to home. Approximately 62% of those events
are considered preventable or able to be improved upon (Foster, AJ;
Murff, HJ; Peterson, FJ, et al.) by:
- Careful discharge planning by
the
hospital staff.
- How well the hospital staff
explains
the treatment plan to the patient.
- How well a patient
understands and
carries out the treatment plan after leaving the hospital.
- Timely follow up by a
physician who is
well informed about the details of the hospital stay.
Seniors are at a higher risk for hospital readmissions because they
typically have more health issues to consider for their discharge,
making their treatment plan more complicated. Also, while
seniors represent approximately 12% of the total U.S. population, they
account for 70% of hospitalized patients (Census Bureau of Statistics),
making them the most vulnerable to discharge procedures.
The physician who is responsible for discharging a patient writes a
discharge summary. It specifies the course of treatment while in the
hospital; the patient’s status at the time of discharge; and the
recommendations and expectations for treatment after the patient is
released, such as follow-up visits with the doctor, medications,
allowed activities, rest recommendations, and diet requirements. The
likelihood that a patient will experience complications after discharge
and will be readmitted to the hospital increases if:
- The discharge care providers
(doctors,
nurses, discharge planners) do not clearly communicate the instructions
on the discharge summary .
- The patient does not
understand the
instructions. This can occur because of language barriers, use of
uncommon medical terms, or if the patient receives too much information
to follow.
- The patient does not follow
through on
the instructions, either because they don’t understand them or they
choose not to abide by them.
- Results from tests taken
while in the
hospital are not available at the time of discharge, and therefore, are
not included on the discharge summary. Furthermore, these test results
may not be forwarded to the physician who performs the follow up visit.
- The physician who performs a
follow-up
visit with the patient does not have access to or has not reviewed the
discharge summary, and therefore, does not have all necessary
information.
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Getting
the Best Possible Care at the Time of Discharge
Doctors
at the Boston University School of Medicine and the Texas Medical
Institute of Technology completed a study of care
transitions.
This study resulted in the Reengineered Discharge (RED) Process, a list
of recommendations for the hospital staff to follow for improved
patient discharge. To ensure a senior patient is getting the
best
possible care at discharge, patients and their families can
watch
to ensure that the hospital personnel completes the items on this list.
Principle Themes of the RED
Process:
- The
patient is being educated throughout their hospital stay about their
condition and necessary treatments after being discharged.
- Information
about the patient’s care in the hospital is flowing from the patient’s
primary care physician (whether or not he is the attending
physician in the hospital or not), to the hospital team and back to
the primary care physician.
- Every
discharge must have a written discharge plan that is comprehensive in
scope and addresses medications and other therapies, dietary
and
other lifestyle modifications, follow-up care, patient education and
health literacy improvements, and instructions about what to do if
their condition changes.
- Every
discharged patient should have a comprehensive discharge plan completed
before discharge, and a copy should be provided to the patient at
discharge.
- All patients should have access
to discharge information in their language and at their literacy level.
- Patients
at risk for re-hospitalization should have the discharge plan
reinforced after discharge. This follow up can be done by family
members, the primary care physician, or care transition professionals.
- All information about the
patient’s hospital admission must be organized and promptly delivered
to the primary care physician.
Source: © Lippincott Williams
& Wilkins, 2007
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The path your medical records take after your discharge largely depends
on the practices of the hospital where you were admitted. The goal is
to get your medical records to your primary care physician, but this
can be confusing. Generally, the system works like this: If
your primary care physician was your attending physician in the
hospital, he will have your hospital records forwarded to him.
Otherwise, the attending physician is responsible for directing copies
to your primary care physician, but this is addressed on a case-by-case
basis. In all cases, your primary care physician can request your
hospital records; he just needs to know that you have been in the
hospital. So, when you are admitted, you need to remember to
list your primary care physician.
According to the Society of Hospital Medicine (www.hospitalmed.org),
“The interval between hospital discharge and the continuity provider’s
first post-hospital patient visit is being increasingly recognized as a
hazardous hiatus. The patient is vulnerable to a variety of factors
that may result in morbidity or hospital readmission, including the
recurrence of symptoms that prompted the initial hospitalization,
adverse drug events from new medications, new drug-drug interactions,
or issues of care coordination, such as follow-up visits and tests.
Inadequate social support can further exacerbate the medical complexity
of care transition from the inpatient to the outpatient setting.”
The Centers for Medicare and Medicaid Serves (www.cms.gov)
requires
that all patients are assessed on the basis of cognition, mobility, and
family support before being discharged from a hospital. For true
success in the “transition of care” from the hospital to home or to a
skilled care facility, the big picture for a patient also means taking
into account coordinating medications, planning follow up doctor visits
and tests, activating supportive community resources, acquiring durable
medical goods if needed, and arranging home health care if necessary.
Care transition professionals are available to assist patients and
their caregivers with the transfer process and help them succeed in
setting up a new health care approach according to the doctor’s orders.
These professionals include the hospital’s discharge planner, social
worker, geriatric care manager, transition care companies, and more.
Patients may be responsible for the fees associated with the services
provided.
"If we can make sure you get your medications and understand your
condition and make sure you get to your follow-up appointments, it
would make a world of difference and keep you out of the hospital,"
says Kathleen Mayeda, coordinator of Homecoming Transitional Care
Network, a San Francisco organization that receives private and city
funding to help seniors and people with disabilities with their
post-hospitalization needs.
When a senior enters a skilled nursing or rehab care facility, family
members or a designated care transition professional can work with the
patient and the facility’s care providers to assure a solid and
beneficial care plan is put into place.
The patient and the family members actually have a lot of control over
how well the transition period from hospital to home or skilled care
facility can go, and they can decrease the chance for difficulties
after leaving the hospital.
Tips for a more successful transition experience are:
- If someone else will be
involved with
your care after you leave the hospital, he or she should be present at
the time of discharge to hear instructions and ask questions.
- Ask to work with the
hospital’s
discharge planner. Every hospital has one.
- Be certain that you
understand all of
the instructions given to you. If you are not sure, ask the doctor,
discharge planner, or nurse for further explanation.
- Pick up all medications
prescribed to
you and take them according to the prescription.
- Learn how to properly change
bandages
and clean wounds, if necessary.
- If you need durable medical
equipment
or home health care, work with the discharge planner or social worker
to make arrangements.
- Make sure your primary care
physician
receives a copy of the discharge summary and all test results from the
hospital. Again, the discharge planner can help arrange this.
- Be sure you leave the
hospital with
full written instructions about your condition, medications, dietary
restrictions, recommended activity and rest levels, which symptoms you
should expect, what to do if you feel worse after you leave, follow up
doctor visits and tests, etc.
Medicare offers patients and caregivers a useful guide to be used at
the time of discharge called “Your Discharge Planning Checklist.” A PDF
version of the list can be found at: http://www.medicare.gov/publications/pubs/pdf/11376.pdf.
Because hospital readmission rates are used as a measure of hospital
care, hospital discharge procedures have long been, and continue to be,
under review. Hospitals are reviewing their own discharge
procedures, as are numerous studies by universities and other entities,
such as the University of Nebraska’s College of Engineering and the
Agency for Healthcare Research and Quality.
Now more than ever, hospitals
are held accountable for their quality of care because of a provision
in the Patient Protection and Affordable Care Act that became law in
March 2010. Information about specific hospitals’ readmission rates is
now more readily available to the public. It is posted and regularly
updated on the Secretary of Health and Human Services Hospital Compare
website: www.hospitalcompare.hhs.gov.
In June 2009, The Centers for Medicare & Medicaid Services
(www.cms.gov)
began publicly reporting 30-day readmission rates for
patients who had been hospitalized and discharged with pneumonia, acute
myocardial infarction, or heart failure – all of which are more common
ailments for hospitalized seniors. Patients discharged with
one of these three conditions are monitored for hospital readmissions
through a Medicare rating system of “excess” vs.
“expected.” Under the new health care reform law,
hospitals are now required to report patient data to the Secretary of
Health and Human Services. The results of the data gathered
to date show that about one in five Medicare patients are readmitted
within 30 days after being discharged. Beginning fiscal year 2012,
hospitals with “excess” readmissions will face financial penalty by CMS
who will be allowed to withhold a percentage of all inpatient Medicare
payments.
The next time you or a loved one faces a stay at the hospital, make
sure that when you exit the hospital, you have all the information you
need to succeed in your new care plan. The care plan may be short-term
or long-term, but arming yourself with information about your
condition, enlisting the right kinds of support, and committing to your
own health care plan will help decrease your chances for a hospital
readmission and increase your opportunities for better and faster
recovery.
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