Care Transitions Made Easy. Moving from Hospital to Home

Why Care Transition Matters 

  The average hospital stay has shrunk due to the downward pressure from operational costs and improvement in outpatient care. In healthcare systems around the world, length of hospital stay is used as an indicator of healthcare quality and so there is a motivation to discharge the patient as soon as they are ready. But such impetus for a quick discharge is not without its dangers, especially when the patient eventually ends up returning to the hospital with the same symptoms or in worse condition than before. It is why care transitions has come to forefront, which ensures a continuity of care as the patient moves from one setting to another and accountability is transferred from one care team/personnel to another.  

   If care transition is not done right, the health system is not only risking bad patient experience, but lower quality healthcare as well in the form of readmissions. To illustrate the threat of readmissions, in USA, 20% of Medicare Patients return to the hospital within 30 days, costing more than $26 billion annually. In Canada, around 9% of patients are readmitted to the hospital within 30 days of discharge, costing $2.1 billion a year.  For UK, this figure is 8%, causing the NHS 1.6 billion per year. 

Focusing on Hospital to Home Care Transition 

  The most frequent care transition that occurs is that from a hospital to home. This post focuses on transitioning from hospital to the home because one can make the biggest impact by focusing on this one transition.  It was found in a study by Journal of American Medical Association (JAMA), that patients discharged into home health care had a higher readmission rate than patients discharged to a skilled nursing facility. Those two post-acute care settings were considered for the study as 90% of Medicare patients are discharged into one of those two settings. It is not hard to guess why home care had a higher readmission rate as they were not privy to the intensity of care around the clock found in a Skilled Nursing Facility. The home is not a structured setting supervised by anyone. More than any other setting, the patient has a greater degree of accountability. Any need for help from caregivers, or any arrangements to avail services from community organizations need to be assessed and explained to them before they walk out of the hospital doors. Such activities comprise of one’s care transition. 

The Need for Simplification 

Transitioning patients from hospital to home without any further complications or readmissions is key to achieving value-based healthcare. There are slight differences between the type of care transition models that have been tested before. But usually, they all contain active issues, required services, warning signs to look out for, and who to connect 24/7 for emergency. More specifically, they always contain certain steps in the timeline of the patient which are centered around the discharge plan. We simplify the process in this post. The diagram below provides an overview, and each activity is further explained in the following paragraphs.  

Care Transition Made Easy

 The Discharge Plan 

  If Care Transitions was a car, the discharge plan would be the engine. As hospitals are under pressure to discharge the patient which is seen as a sign of both quality and cost efficiency, the discharge plan is the preferred mechanism by which all expectations of what is to come is laid out. It is found through systematic reviews, that enhanced discharge planning is a contributing factor to lowering readmissions. Discharge instructions are reviewed with the patient. It educates them on their diagnosis and the extent of evaluation performed on them. It also outlines a medication management plan, any follow up visits where they have to see their primary physician, and a scheduled home visit from a nurse and/or social worker.  

  Understanding discharge instructions is a major issue. Patients may not be unable to remember such sessions as they are not at the right mindset, or because they have undiagnosed dementia. Social factors could also be at play in understanding and adhering to the plan, such as the patient not being able to read and not having the money to pay for medications. This is why no assumptions should  be made when the patient is ready to leave the hospital. 80% of serious medical errors happen because of miscommunication during the hand-off between medical providers. It is not only the job of the incumbent healthcare professional to explain to the patient what is about to happen, but also update their care provider, usually primary care physician, on the same things. The discharge plan is the sheet agreed on which outlines the next steps and expectations from all parties. But how does one write such a plan?  Let’s backtrack a few steps. 

Going Over Discharge Plan
Going over the Discharge Plan 

The Daily Rounding 

  Rounding is the process of visiting the patient to have meaningful conversations on their status, to explain the care they have been receiving and uncover improvement areas. It is has become a nursing best practice over the years. Normally one would teach the patient how to self-care and self-manage medications. But by conducting such a process daily or in more frequent intervals where necessary, one can begin to assess risks such as low literacy, presence of other conditions, other recent readmissions, medication history etc. By looking at the patient’s EHR and by interviewing them when they are able to speak, one can assess their social and economic situation which can be used to assemble a post-acute care transition plan that will bring everyone to the same page on the status of the patient. At such a stage, it is crucial to exchange informational electronically with all those that need to be involved in the patient’s care. Any primary care physician should be identified by name at the bare minimum, as should any nurse, social care worker or informal caregiver that will be visiting them or caring for them. It is best if a coordinator or navigator is assigned to the patient who can be the first point of contact for the patient. Care coordinators are further explored in our article about Care Coordination(will be linked once posted). Once all such input is gathered and verified, it is possible to finalize the care transition plan and disseminate the information via a discharge meeting. It’s crucial to explain the information to the patient in their preferred language and use pictures to reinforce the message if necessary. 

 The Follow Up 

  The staff must be trained to do follow up visits. It is common in all care transition models. Nurses from patient’s primary physician’s office or home care agencies have a very important task in following up with the patient. They must make sure the patient is taking their medication in the correct dosage. They must notice if there any furniture in the house that can be fall hazards, and see if they need any supportive furniture like bathroom safety bars. They must see if they have proper access to transportation, meals, caregivers (if needed), etc. The follow up visit would be an opportunity to do another assessment and keep the patient healthy at home. But readmissions may and do still occur. 

The Closing of the Loop 

  If there is another readmission by any chance, it is important to find out what lead to it or one is doomed to repeat the pattern. Even after a well thought out and communicated discharge plan, some areas may have been overlooked.  In such instances, it is important to learn what caused the readmission so such learning can be incorporated into the next discharge plan. Also, it is important to collect the patient’s feedback on the quality of the transition of care. Healthcare is a two-way street, and to truly buy the engagement and cooperation from patients, it’s necessary to hear their side of the story about the whole process. 

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