Risk Specific Interventions
Once you have completed 7P risk assessment and identified the patient’s high risk characteristics, you should begin planning the patient’s transition. This process highlights that transition planning begins on admission and progresses throughout the hospitalization. Of note, additional risk factors may be identified during the hospitalization (e.g. initiation of a high risk medication or development of a high risk principal diagnosis). If this occurs, institutions are encouraged to review the 7P risk specific interventions and consider implementing them during the hospitalization or prior to discharge, as feasible and appropriate.
In addition to risk specific interventions, all patients should receive all the components of the Universal Patient Discharge Checklist:
General Assessment of Preparedness (GAP) assessment completed with issues addressed.
The GAP is a list largely derived from a study of patient preferences of common logistical and psychological areas that, when not addressed, may act as barriers to a patient’s ability to receive or obtain the care the patient needs (Grimmer K, Moss J, Falco J, Kindness H. Incorporating patient and carer concerns in discharge plans: the development of a practical patient-centered checklist. Internet Journal of Allied Health Sciences and Practice 2006:4(1).). This section might be addressed by a combination of the case manager, the nurse, and the social worker (see General Assessment of Preparedness: the GAP. The QI team should address the following questions: When should this be completed? How are issues identified linked back to the care team resolved? Who has responsibility for resolution? Is this a final pre-discharge list or one that should be addressed periodically during the patient’s stay?
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Medications reconciled with preadmission list.
It is important that a patient’s pre-hospital medications are reviewed at admission, during transfers in the hospital, and at discharge and that changes to the medication list are reconciled. In fact, this is mandated by the Joint Commission. Many institutions have created mechanisms for completing this process, and examples of forms used for this process can be found on the Massachusetts Coalition for the Prevention of Medical Errors website. You should feel free to modify these as needed for your institution. The MATCH (Medications at Transition Changes and Handoffs) project focuses on medication reconciliation, and its Web site provides a thorough explanation of how to approach the process and has useful tools.
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Medication use/side effects reviewed using teach-back with patients/caregivers.
Among medical patients, medication-associated complications, so-called adverse drug events (ADEs), are the most common type of adverse event after discharge.(Forster, Murff et al. 2003; Forster, Clark et al. 2004; Forster, Murff et al. 2005) Using the teach-back technique, ensure that patients and their caregivers understand how, when, and why to use their medications, what key side effects they should look out for, and what to do if they arise.
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Teach-back used to confirm patient/caregiver understanding of diagnosis, prognosis, self-care requirements, and symptoms of complications requiring immediate medical attention
As above, using teach-back, work with patients and their caregivers to educate them about the care requirements they should expect after discharge, about anticipatable potential complications of their illness, and about how to address them if they arise.
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Action plan for management of symptoms/side effects/complications requiring medical attention established and shared with patient/caregiver using Teach-Back.
Empowerment of the patient and caregiver to be knowledgeable regarding how to manage predictable events after discharge is important. Part of this process is ensuring they understand why, when, and how to access medical attention. In doing so, you may result in a reduction in inappropriate hospital utilization.
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Discharge education plan completed, taught, provided to patient/caregiver at discharge.
This element is usually completed just prior to discharge but should be started much earlier during the hospitalization. Take advantage of the opportunity for repetition and reinforcement when time affords it in order to highlight key messages (e.g., for the patient initiated on warfarin, begin the teaching process about the medication when it is begun, not just at discharge). In the section below, Written Discharge Plan, (insert LINK) you will find further instructions on the quality, elements, and literacy issues relevant to the discharge plan. See also the Patient PASS and Discharge Patient Education Tool (DPET) for examples and the Massachusetts Coalition for the Prevention of Medical Errors website for an example of a patient-centered medication list, a critical element to include in all patient preparation processes.
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Discharge communication provided to post-hospitalization care providers.
Ample literature identifies the frequent delays between the time of patient discharge and written communications regarding the hospitalization reaching the principle care providers. Often, the discharge summary fails to arrive before follow-up visits and is surprisingly inadequate or incomplete for the needs of these providers.(Kripalani, LeFevre et al. 2007) Discharge summaries or letters should be provided to the patient’s outpatient providers within 48 hours of discharge, if not at the time the patient is leaving the hospital. The Clinical Tools section of the room provides a template for the discharge summary, which includes necessary information that should be sent to the patient’s principal outpatient provider. Of note, 7P associated risk factors should be communicated to principal care providers in the discharge summary as an outstanding issue.
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Documented receipt of discharge information from principal care providers.
As recommended by the National Quality Forum’s Safe Practice on Discharge (2006), hospitals should confirm that the patient’s principal outpatient provider receives the discharge summary. This requires a tracking mechanism and may be in any format viable in your organizational structure, from a phone call (documented in your record) to a secure e-mail or a return fax.
For those patients who are felt to be at particularly high risk and may or may not have been otherwise identified by the 7P scale, institutions may choose to include the following strategies to reduce the risk to the patient of an adverse event after discharge:
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Direct communication with principal outpatient provider at discharge.
Communications between inpatient and outpatient providers often occurs via mailed or faxed materials. Given the busy schedules of both parties, bidirectional conversations (e.g. phone communication) may prove complex. Nonetheless, in high risk subsets of patients, this type of communication is encouraged as a way of closing the communications gap while the patient prepares for discharge. This should take place in addition to sending the patient home with a patient-oriented discharge plan and the creation of the formal discharge summary to be mailed out later This brief communication should address the identified risk factors, the primary issues of the hospitalization (including therapies initiated and discontinued), and outstanding issues, tests, appointments, and follow-up plans for the patient.
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Telephone contact arranged within 72 hours of discharge in order to assess the patient’s condition and adherence and to reinforce follow-up.
Several researchers have found that despite excellent in-hospital discharge planning, numerous issues arise once the patient leaves the hospital. For patients at increased risk, we recommend a phone call to patients (or caregivers) within 48-96 hours of discharge to assess patients’ clinical status, their ability to receive planned treatments (e.g., Could they get their medications? Did the visiting nurse come to help them with their dressing changes?), their recall of follow-up plans, and any other issues they may have.
Who makes this call depends on the infrastructure and organization of the hospitals or health system. Researchers and practitioners, utilizing the post-discharge follow-up phone calls, have had this performed by nurses, pharmacists, and, less commonly, physicians.(Insert Naylor, Shnipper, and Dudas refs) Another question is whether the hospital-based team should initiate the call or whether this should this be done by the outpatient care provider to reforge the therapeutic bond after the hospitalization. Because of insufficient research in this area, we believe the best approach is a local decision. What is clear is that the individual making the call should have some clinical expertise and be familiar with the issues faced by the patient at the time of discharge.
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