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Hospital discharge
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2012. | This topic last updated: Dec 19, 2011.

INTRODUCTION — Discharging patients from the hospital is a complex process that is fraught with challenges. Preventing avoidable rehospitalizations has the potential to profoundly improve both the quality-of-life for patients and the financial well-being of healthcare systems.

There were over 39 million hospital discharges in the United States in 2006 [1]. Among Medicare patients, almost 20 percent who are discharged from a hospital are readmitted within 30 days [2]. Unplanned rehospitalizations, at a cost of $17.4 billion, accounted for 17 percent of total hospital payments from Medicare in 2004 [2,3].

While the exact number of avoidable readmissions is unknown, between 9 and 50 percent of readmissions were judged to be preventable in studies involving retrospective chart review [4]. Decreasing the rate of hospital readmissions has been targeted as a high priority for US health care reform [5].

This topic presents an overview of the discharge process, determination of the appropriate next site of care, and review of interventions that have been developed to reduce the likelihood of unplanned readmissions and adverse events after discharge. Much of the discussion relates to structures for care within the United States; availability of services and types of facilities vary significantly across geographic areas.

APPROPRIATENESS FOR DISCHARGE

Need for ongoing hospitalization — The medical necessity of continued hospitalization is primarily determined by the presence of an acute health condition of sufficient severity that ongoing diagnostic or therapeutic intervention, or careful monitoring, is required.

However, patients often appropriately remain in the hospital when these criteria are not met, due to the lack of a suitable alternative setting to provide necessary care or other social factors.

Premature discharge or discharge to an environment that is not capable of meeting the patient's medical needs may result in hospital readmission. In addition, early hospital discharge may not lead to overall cost-savings if it results in need for more intense subsequent healthcare utilization, including emergency department or nursing facility visits, as indicated by one observational study comparing patients who received hospital care from a primary care physician with care by a hospitalist [6].

DETERMINING THE POST-DISCHARGE SITE OF CARE — When it has been determined that a patient is medically ready for discharge, the health care team must determine the most appropriate setting for ongoing care. Determinants of the appropriate site of care involve medical, functional, and social aspects of the patient's illness. The patient’s acute and chronic medical conditions, potential for rehabilitation, and decision-making capacity must be taken into account [7].

Input is needed from multiple sources to determine the most suitable discharge plan. Involved parties often will include the patient, family, case manager, nurse, physician, physical and occupational therapist, social worker, and insurer.

In order for the patient to be deemed safe and ready for discharge to home or to a non-acute environment (rehabilitative, transitional, or chronic care), a provider must take into account a number of factors beyond the medical determinants. These factors include:

  • Patient cognitive status
  • Patient activity level and functional status
  • The nature of the patient's current home and suitability for the patient's conditions (eg, presence of stairways, cleanliness)
  • Availability of family or companion support
  • Ability to obtain medications and services
  • Availability of transportation from hospital to home and for follow-up visits
  • Availability of services in the community to assist the patient with ongoing care

Discharge home — Approximately three-quarters of hospitalized patients are able to return to their home environment following discharge [8]. For discharge home, patients, with help from family or other caregivers if available, should be able to:

  • Obtain and self-administer medications
  • Perform self-care activities
  • Eat an appropriate diet or otherwise manage nutritional needs
  • Follow-up with designated providers

Specific insurance benefits and availability of services in the community may also influence whether or not the patient may be safely discharged home. Home services, such as visiting nurses or infusion providers to administer intravenous infusions, may allow selected patients, who would otherwise need nonacute residential care, to manage their care needs at home.

Discharge to another care facility — If discharge to the outpatient setting is not appropriate, the team must then arrange transfer to another inpatient facility for ongoing care. Determining the most appropriate inpatient setting of care for ongoing treatment involves determining the patient's needs and matching needs with the capabilities of potential sites of care.

One model to help accomplish this involves assessing a set of parameters that describe generic clinical characteristics (medical and surgical issues, mental and emotional status, physical functioning, and environment) that are largely independent of the patient's specific diagnosis [9]. Components of this model are shown in a table (table 1). These needs are then matched with the services offered at different types of facilities. (See 'Types of care facilities' below.)

Once it is decided that discharge to an alternate facility is necessary, referrals are made to facilities that are felt to be potentially appropriate, and the patient is screened for acceptance. The patient must consent to transfer to an accepting facility; if the patient or family declines, then negotiation ensues to find an acceptable discharge placement.

Types of care facilities — The severity of functional impairments and the need for assistance with activities of daily living (ADLs) often determines whether a patient can be safely managed at home, or requires care at a skilled nursing facility (SNF) or extended care facility (ECF). In making this determination, particular attention is paid to need for supervision in ADLs and safety awareness.

Medicare in the United States identifies three categories of health facilities:

  • Acute care hospitals
  • Exempt hospitals (inpatient rehabilitation hospitals and long-term acute care hospitals)
  • Nursing facilities (skilled nursing facilities and extended care facilities)

Functional capabilities of each of these facilities are shown in a table (table 2) and outlined briefly here:

  • Inpatient rehabilitation facilities — To meet certification criteria, inpatient rehabilitation facilities (IRFs) must admit 75 percent of patients for one of 13 specified diagnoses such as stroke or major trauma. Patients must require multidisciplinary therapy (eg, physical therapy, occupational therapy, speech therapy, orthotic or prosthetic services) and be able to participate in intensive treatment. Physician supervision is provided at least three days per week.

    The patient's stay at the IRF may continue as long as there is continued progress and the ability to participate in and to benefit from at least three hours of therapy per day.
  • Long term acute care hospitals — Long term acute care hospitals (LTACs) must maintain an average length of stay ≥25 days and patients must require daily monitoring and complex medical interventions. Patients may include those with complex wounds, chest tubes, ventilatory dependency, or multiorgan failure. LTACs are more likely to take complex medical patients than IRFs, and are less widely geographically distributed than IRFs, although the number of LTACs in the United States more than doubled between 1997 and 2006 [10].
  • Skilled nursing facilities — Skilled nursing facilities (SNFs), transitional care units (TCUs) and subacute units provide similar services. TCUs are hospital-based and therefore have more ready access to hospital-based services.

    To qualify for Medicare coverage in these facilities, patients must have a "qualifying event" that includes a three night hospital stay, and must require skilled nursing or rehabilitation for at least one hour daily five days a week. Medicare SNF benefits last 100 days without a new qualifying event and most SNFs do not accept high cost patients for admission.
  • Extended care facilities — Extended care facilities (ECFs) provide long term custodial care reimbursed through Medicaid. In order to qualify for Medicaid, a patient must have exhausted his or her assets, require assistance with a least three activities of daily living (ADLs) and require skilled nursing supervision (medication management). Medicaid does not cover therapy services or skilled care, aside from the Medicare copayment.
  • Home-based services — Availability of home-based services is highly variable. Multiple domains may be addressed by home-based care, including services provided by Medicare-certified home health agencies, private duty nursing services, hospice, infusion services, physician home visit programs, hospital-in-the-home, and telemedicine.

ELEMENTS OF THE DISCHARGE PROCESS

Discharge planning — Discharge planning is the development of an individualized discharge plan for the patient prior to leaving the hospital, to ensure that patients are discharged at an appropriate time and with provision of adequate post-discharge services [11]. Such planning is a mandatory part of hospital accreditation [12].

Discharge planning is a complex process that seeks to determine the appropriate level of services required by the patient and then match the patient to an appropriate site of care [13]. This process ideally begins at the start of the hospitalization. The hospital case manager should be involved as soon as it is clear that the patient will require services at home, or will require transfer to an alternative level of care.

The impact of discharge planning on outcomes appears to be limited. A 2010 systematic review identified greater patient satisfaction and small decreases in length of stay and readmission rates with discharge planning, while mortality rates were unchanged [11]. A study that examined discharge planning for patients with heart failure measured chart documentation of discharge instructions and patient reports of the discharge planning they had received [14]. No correlation was found between readmission rates and the chart-based measure, and only a small correlation was noted for lower readmission rates with highest versus lowest quintile on the patient-reported measure (22.4 versus 24.7 percent).

Medication reconciliation — Medication reconciliation is the process of verifying patient medication lists at a point of care transition, such as hospital discharge, to identify which medications have been added, discontinued, or changed relative to prior medication lists.

The ability to generate an accurate discharge medication list requires detailed knowledge of the patient's prior medication history and hospital course, as well as clinical judgment to determine which medications will be continued after hospitalization. The ability to communicate this information effectively to the patient and/or subsequent caregivers is essential to the process.

An accurate medication list at hospital discharge is contingent upon the following factors:

  • Availability of an accurate list of medications taken just prior to hospitalization. This list may have been assembled at the time of admission, and revised during the hospitalization if new information became available, to reflect the prehospitalization medications.
  • An accurate and available list of medications being taken at the time of discharge.
  • For changes in medication that occurred during the hospital admission, knowledge of why such changes were made. As examples:

  • If a proton-pump inhibitor (PPI) was newly prescribed, was this initiated for prophylaxis of stress ulceration and therefore no longer required, or is ongoing PPI therapy necessary for treatment of an ulcer?
  • If a different agent from the same class as one taken prior to admission was substituted during the hospitalization, was there a clinical indication for making that change or does this represent a hospital therapeutic substitution related to formulary preference? If a therapeutic substitution, the medication should revert to the medication that the patient was taking prior to hospitalization.

Evidence of the effectiveness of medication reconciliation has been limited. Studies include the following:

  • In one study, an intervention in which pharmacists obtained medication histories at patient hospital admission and compared lists to those obtained by physicians led to a change in orders for over one-third of patients [15]. One-half of the errors were considered potentially harmful.
  • In Sweden, patients 80 years or older who were randomly assigned to receive a medication reconciliation intervention by unit-based pharmacists had 16 percent fewer visits to the hospital and 47 percent fewer emergency department visits than controls [16]. Medication-related readmissions were reduced by 80 percent.
  • In a randomized trial, patients who received an intervention consisting of medication reconciliation by a pharmacist prior to discharge followed by a post-discharge phone call had a lower rate of preventable adverse drug events at 30 days compared to controls [17].
  • At an academic medical center, patients deemed high risk for an adverse drug event after discharge were randomly assigned to receive no intervention or a pharmacy facilitated discharge, including medication reconciliation, medication education, adherence assessments, and a follow-up phone call at 72 hours and 30 days post-discharge [18]. Despite identifying and correcting medication discrepancies at discharge in one-third of patients in the intervention group, there was no difference in rates of readmission or emergency department visits compared to controls.

Medication reconciliation at points of care transitions was adopted as a National Patient Safety Goal for 2006 by The Joint Commission. Though recognized as an important concept in safety, medication reconciliation is hampered by several unresolved operational issues including:

  • Who should perform medication reconciliation (eg, nurse, pharmacist, physician)?
  • How can resources (personnel, systems) be most effectively allocated to perform medication reconciliation, and reimbursement attached to safety-oriented, time-consuming tasks such as medication reconciliation?
  • How should one determine the "gold standard" list of medications for individual patients, to use as the basis for reconciliation?
  • How can aftercare providers reliably be informed of medication changes in a timely and accurate fashion?
  • How can patients and family/caregivers be engaged in understanding the importance of medication reconciliation?

Difficulties with implementation by hospitals led to a subsequent decision to temporarily suspend this requirement for accreditation. In October 2010, a multi-organizational white paper suggested principles of effective medication reconciliation. These core principles were endorsed by multiple agencies including the American Medical Association, the American College of Physicians, the American Association of Critical-Care Nurses, as well as The Joint Commission [19]. Thereafter, The Joint Commission released their updated medication reconciliation standard [20], which is less prescriptive than the earlier version. The standard focuses on patient preparation for the transition, addressing the need for a written list and an explanation about the importance of medication management with the patient or caregiver.

Discharge summary — The primary mode of communication between the hospital care team and aftercare providers is often the discharge summary, raising the importance of successful transmission of this document in a timely fashion. Unfortunately, the discharge summary reaches the primary care provider by the time of the first follow-up visit in only 12 to 34 percent of such visits, and even then often lacks key information [21].

Important elements in the discharge summary, as mandated by the Centers for Medicare and Medicaid Services, are [22]:

  • The outcome of the hospitalization
  • The disposition of the patient
  • Provisions for follow-up care including appointments, statements of how care needs will be met, and plans for additional services (eg, hospice, home health assistance, skilled nursing)

This minimal content should be augmented by information critical to the aftercare providers. Utilizing a template for discharge summaries is helpful to ensure inclusion of relevant information [23]. A suggested list of items that should appear in a discharge summary is shown in a table (table 3). An essential component is identifying those laboratory or other tests for which final results remain pending at the time of discharge [24,25].

Several initiatives involving computer-based innovations to improve the discharge summary process [26] or notification of pending tests at discharge [27] have been explored but issues involving cost and end-user adoption need further consideration. An initiative involving audit and feedback of discharge summaries was successful in improving discharge summary completeness [28].

Patient instructions — At the time of discharge, the patient should be provided with a document that includes language and literacy-appropriate instructions and patient education materials to help in successful transition from the hospital.

These documents should be brief, focused on critical information to the patient, and primarily directed at what the patient needs to understand to manage his or her condition after discharge.

One model for patient materials, developed by the National Patient Safety Foundation, is called Ask Me 3 [29]:

  1. What is my main problem? (ie, why was I in the hospital?)

  2. What do I need to do? (ie, how do I manage at home, and what should I do if I run into problems?)

  3. Why is it important for me to do this?

Discharge information, both written and verbal, should be reviewed with the patient/family caregivers with an emphasis on assessing and ensuring comprehension. Teach back is a technique by which the provider asks the patient or caregiver to explain the recently taught concept in the patient's own words [30]. This permits the provider to identify and correct any misunderstandings. It may also be helpful for teaching a patient a new skill (eg, administering insulin or changing a dressing).

Discharge checklist — Checklists provide an effective mechanism for ensuring that discharge communications (the discharge summary and direct communication with both aftercare providers and patients/families) reliably incorporate all key elements. In 2005, a multi-institutional group created a discharge checklist containing a number of elements that are either required or optional during the preparation of the patient for discharge. This checklist has been endorsed by the Society of Hospital Medicine [31] (table 4). Its effectiveness has not been studied.

FACTORS CONTRIBUTING TO REHOSPITALIZATION — Many hospitalizations are not avoidable. Readmissions may represent progression in the natural history of the patient's underlying disease, a separate problem that is unrelated to the initial admission, or the consequence of patient inability to follow through with a discharge plan (eg, the patient does not fill prescriptions). Additionally, one study using Medicare data for over 200,000 heart failure and pneumonia patients found that high admission rates for those conditions in patients with similar morbidity were correlated with high readmission rates and that this factor contributed to more regional variation in readmission rates than other factors including case mix, discharge planning, hospital size, or number of primary care or specialist physicians [32].

However, many readmissions are likely preventable [4]. The proportion of rehospitalizations that are preventable is uncertain. A systematic review of 34 studies found that the median proportion of readmissions deemed avoidable was 27 percent, but that variable and subjective criteria to define “preventable” readmissions led to a wide range of reported rates between studies [33].

Several factors that increase the likelihood of rehospitalization may be modifiable, especially those that relate to clinician or system level issues. Such factors include:

  • Premature discharge or inadequate post-discharge support
  • Insufficient follow-up
  • Therapeutic errors
  • Adverse drug events and other medication related issues
  • Failed handoffs
  • Complications following procedures
  • Nosocomial infections, pressure ulcers, and patient falls.

Therapeutic error — Medical errors are a major contributor to preventable rehospitalization. Issues related to medication use are a common form of error. Adverse events, most commonly medication-related, have been estimated to occur in approximately 20 percent of patients following discharge [34,35]. Approximately two-thirds of such adverse events were determined to be either preventable or ameliorable.

Examples of these types of errors include:

  • Patients sent home without prescriptions for necessary medications
  • Patients receiving duplicate prescriptions for medications they have at home labeled with a different name (eg, generic and proprietary names)
  • Inadequate monitoring and follow-up for drug side effects

Failed handoffs — Poor information transfer from hospital-based providers to primary care providers occurs commonly. This may contribute to multiple adverse consequences, including the need for readmission, temporary or permanent disability, or death [21,34,35]. Tests that are pending at discharge often fail to be communicated to providers responsible for their follow-up [24,25,36]. Representative studies include the following:

  • In one study, 41 percent of discharged patients had a test pending at discharge. Almost one in ten patients potentially required an intervention, but almost two-thirds of responsible aftercare providers were unaware that a test was outstanding [24].
  • In another study, tests pending at the time of discharge were mentioned in discharge summaries only 25 percent of the time, and the list of pending studies was complete only 13 percent of the time [36].
  • Almost one-third of tests recommended by the hospital-based team for follow-up were never obtained by the after care provider; such tests were recommended for about one quarter of discharged patients [37].

Direct communication from hospital provider to aftercare provider is uncommon, and there are no clear or widely accepted standards about this communication. A meta-analysis revealed that only 12 to 34 percent of discharge summaries had reached aftercare providers by the time of the first post-hospitalization appointment [21]. Additionally, discharge documentation was often inaccurate and lacked important information such as noting additional workup indicated following discharge.

Absent or delayed follow-up — The optimal time interval between hospital discharge and the first follow-up visit to a primary care or subspecialty provider is unknown. Many factors will contribute to this decision including the severity of the disease process being followed, the perceived ability of the patient to provide adequate self-care, and psychosocial and logistical factors.

Several studies have evaluated the association between rates of readmission and scheduled outpatient follow-up post hospitalization. Most studies affirm that patients who are scheduled or seen for posthospital follow-up are less likely to be readmitted [35,38-40]. Findings include:

  • Among Medicare beneficiaries requiring readmission within 30 days of discharge, only 50 percent had seen a clinician for a follow-up visit [2].
  • Another study of Medicare patients hospitalized for heart failure in 225 hospitals found that rates of readmission within 30 days were highest for patients discharged from the quartile of hospitals with the lowest percentage of patients seen for early follow-up (within seven days of discharge) [38].
  • In a small prospective study (n=65), follow-up with a primary care physician (PCP) within 30 days of discharge from an inpatient medical service occurred for only 49 percent of patients [39]. Hospital readmission was ten times more likely in those who did not have a follow-up visit, compared to patients who had a timely PCP visit (OR 9.9).
  • In contrast, however, one retrospective study of nearly 5000 hospital discharges from the general medicine service at the Mayo Clinic hospitals found no difference in 30-day hospital admission, emergency department visits, or mortality comparing patients who had documentation of a scheduled follow-up appointment (median six days after discharge) compared with those who did not [41]. This study, however, did not document whether those patients had actually attended the follow-up appointments or whether attending the follow-up visit resulted in changes in outcomes.

Higher-risk patients — Efforts to prevent readmissions can be targeted to patients known to be at a higher risk for readmission. Screening for increased risk may help healthcare providers and organizations target resources to patients most likely to be rehospitalized. There are several caveats to this approach, however:

No screening tool will be perfectly accurate. Studies have found that providers are not able to accurately predict which patients will require readmission [42]. Efforts to develop prediction models for patients at high risk for rehospitalization have yielded only fair discriminative ability [43,44]. Additionally, in a systematic review of 26 models developed to predict rehospitalization, only one model focused on the prediction of preventable readmissions [45].

  • Given the variability of resources, patient demographics, and case mix, it will be necessary to adjust risk prediction models for local factors.
  • There will be patients with very advanced disease or complicated social situations for whom no intervention will prevent readmission. Often efforts to decrease hospitalization are most effectively directed towards those patients with intermediate levels of risk for whom interventions might be successful [46].
  • A guiding principle for using risk assessment is understanding how to implement interventions that target the risks identified by the assessment process.

Several studies have suggested clinical and demographic parameters that may increase the risk of readmission. Clinical factors include the following:

  • Use of high risk medication (antibiotics, glucocorticoids, anticoagulants, narcotics, antiepileptic medications, antipsychotics, antidepressants, and hypoglycemic agents) [35,47-51]
  • Polypharmacy (five or more medications) [52]
  • Specific clinical conditions (eg, advanced COPD, diabetes, heart failure, stroke, cancer, weight loss, and depression) [51,53-60]

Demographic and logistical factors include:

  • Prior hospitalization, typically including unplanned hospitalizations within the last 6 to 12 months [59,61-65]

  • Black race [51,66] 
  • Low health literacy [67]
  • Reduced social network indicators like being alone most of the day with limited or no family or friend contact by phone or in person [65]

The LACE index [68] has similar discriminating ability to other models, although may have some advantage in terms of simplicity. This model incorporates the patients length of stay (L), the acuity of the patients admission (A), the degree of comorbid illness (C) as measured by the Charlson Comorbidity Index, and the number of times the patients has been to the Emergency Department in the last six months (E).

DISCHARGE AND POST-DISCHARGE INTERVENTIONS — Efforts to re-engineer the discharge process to assure a safe transition involve such issues as improved clinician communication, patient education, IT systems, involvement of community-based providers, and arrangements for prompt follow-up [69]. Such interventions have the potential to substantially improve patient care and reduce healthcare expenditures.

Researchers involved in the expanding field of Transitions of Care (TOC) are evaluating the effectiveness of various approaches to improving the discharge process. One classification scheme to categorize these interventions is to consider them as: predischarge interventions (patient education, discharge planning, medication reconciliation, scheduling a follow-up appointment); postdischarge interventions (follow-up phone call, communication with ambulatory provider, home visits); and bridging interventions (transition coaches, patient-centered discharge instructions), physician continuity between inpatient and outpatient settings [69]. Several predischarge interventions (discharge planning, medication reconciliation, templated discharge summaries, and discharge checklists) are discussed above. (See 'Elements of the discharge process' above.)

A 2011 systematic review of interventions to reduce discharge identified 43 relevant studies, 16 of which were randomized trials and the remainder observational studies [69]. Most involved small numbers of patients (only two included more than 400 patients), and many studies had quality limitations, including incomplete data and the possibility of unrecorded rehospitalization at another institution, estimated to miss 20 percent of such events. Only 5 of the 16 randomized trials demonstrated significant improvement in rehospitalization rates, and four of the five successful studies involved several simultaneous interventions, including patient-centered discharge instructions and a postdischarge telephone call.

Many multidisciplinary initiatives, known as disease management programs, have targeted patients with specific chronic diseases, to provide patient support, counseling, monitoring, and medication oversight through the continuum of care, including ambulatory, hospital, and hospital discharge settings. Disease management programs involving patients with heart failure are reviewed separately. (See "Strategies to reduce hospitalizations in patients with heart failure".)

Telephone call — Studies have looked at the impact of a telephone call from a member of the health care team following discharge on varying parameters of patient management. These calls have been initiated by various members of the care team, including:

  • The discharging clinician
  • A clinical pharmacist
  • A clinician from the patient's primary care clinic

Such calls have been moderately effective at reducing emergency department visits [70] and improving follow-up with ambulatory providers [71], but demonstrated a trend towards reduced hospital readmissions in only one study [70]. A 2006 systematic review was unable to define a clear benefit from this type of intervention due to significant heterogeneity in the quality and design of this literature [72].

Home visits — Home visits made by a number of different types of providers have been shown to reduce need for rehospitalization. One trial illustrated that a single home visit by a nurse and pharmacist to patients discharged with a diagnosis of heart failure, with a goal of optimizing medication management, showed a trend towards almost a 50 percent reduced risk of unplanned readmission [73]. Other studies looking at this question did not have as dramatic an effect on reduction in rehospitalization [74,75].

Telemonitoring — Use of telemonitoring devices have also been studied as a means for reducing readmissions. As an example, using an integrated telephonic stethoscope in conjunction with follow-up nursing calls in patients with heart failure reduced emergency department visits in one small study, and demonstrated a trend toward reduced readmissions and overall costs [76]. Devices for remotely monitoring various physiologic variables, including blood pressure, heart rate, weight, and oxygen saturation have been repeatedly studied, mostly among heart failure patients, and have demonstrated variable effectiveness in reducing need for readmission [77].

Multiple interventions — Given the complexity of transitions of care associated with hospital discharge, several groups have developed and evaluated programs incorporating multiple initiatives to address many elements in the discharge process. Examples of such programs include:

  • A randomized controlled trial at a large academic safety net hospital evaluated a multidisciplinary team effort that included the following intervention [78]:

  • A nurse discharge advocate to assist with discharge planning and preparation
  • A clinical pharmacist to call the patient two to four days following hospital discharge, to review the medication list, address any medication questions or concerns, reinforce the plan, and assess for adverse effects related to medications
  • Follow-up appointments scheduled at times convenient to the patient
  • Medication reconciliation
  • A low literacy discharge instruction booklet for patients, also provided to the primary care clinician

Post discharge, the rate of hospital utilization (emergency department visits or hospital readmissions) was 31 percent for the intervention group compared to 44 percent for the control group. Patients in the intervention group were also more likely to follow-up with their primary care provider.

  • Another study evaluated the Care Transitions Intervention (CTI) program in which older patients were paired with a nurse transition coach at the time of the discharge. The role of the Transition Coach was to facilitate patient self-management (or management by a family care giver) rather than provide direct care [79]. The coach encouraged the patient to maintain a personal health record, to obtain timely follow-up appointments, to provide self-care, and to understand what to do should problems arise. The transition coach met with the patient prior to discharge and at home two to three days after discharge, followed by three telephone calls over the first 28 days post discharge. This intervention reduced 30 and 90 day rehospitalization rates (8.3 versus 11.9 percent and 16.7 versus 22.5 percent, respectively) with a cost savings of approximately $500/case.
  • Components of the CTI program were implemented in the “real-world” setting of a sample of fee-for-service English-speaking Medicare patients being discharged home for specific cardiac or respiratory conditions from six hospitals in Rhode Island [80]. Readmission rates within 30 days were lower for patients who received coaching compared to data from Medicare claims of an “external control group” of discharged patients with similar diagnoses who were not offered the intervention (OR 0.61, 95% CI 0.42-0.88). Readmission rates for patients who either declined the program or were lost to follow-up before a home visit were no different than for the external control group. Overall, 55 percent of patients who were approached accepted participation and there was a 75 percent attrition rate for home visit participation.
  • Another intervention assigned transitional care partners (advanced practice nurses) to 239 elderly heart failure patients, a subset of patients with very high rehospitalization risk [81]. The designated partner met with the patient daily during the index visit, made a home visit the day after discharge and at least weekly thereafter over the first three months, with one of the visits corresponding to the first follow-up visit to the patient's clinician. In a randomized trial, at one year, there were 104 readmissions among intervention patients, compared with 162 readmissions for control patients, resulting in a cost savings of $4845 per patient.
  • A prospective study of a nurse-led transitional care program for patients with heart failure being discharged from one US hospital compared 30-day readmissions, length of stay, and 60 day direct costs with heart failure patients concurrently discharged from other hospitals within the same healthcare system [82]. The program was associated with a 48 percent decrease in 30 day readmissions but had little impact on direct costs to the healthcare system over 60 days, and under the existing Medicare reimbursement system had a negative impact on hospital revenue.
  • A randomized trial in six geriatric inpatient units in France evaluated the effect of a multimodal intervention (comprehensive medication review; self-management education focusing on medications, depression, and nutrition; and detailed communication around transition-of-care) on rehospitalization [83]. Rates for rehospitalization and ED visits were lower at three months (a secondary outcome), but not at six months (the primary outcome), for the group assigned to the intervention. The intervention included implementation by a geriatrician dedicated to the project, and thus might not be readily reproducible outside of the research project.

CLINICIAN RESOURCES — Several program initiatives are underway to investigate and facilitate interventions to promote improved hospital discharge processes. These programs and their websites include:

  • The National Transitions of Care Coalition (www.ntocc.org) - This site offers tool and resources for both patients and providers to help improve the safety of healthcare transitions. Many of the tools are offered in languages other than English.
  • The Institute for Healthcare Improvement (www.ihi.org) - This site contains numerous resources about care transitions, as well as other quality-related components of healthcare in the United States.
  • The Care Transitions Program (www.caretransitions.org) - This site contains information about the Care Transitions Programs, and contains tools for implementing this program, discusses policy implications surrounding care transitions, and information about personal health records. Some features are translated into Spanish and Russian.
  • Project BOOST (Society of Hospital Medicine) (www.hospitalmedicine.org/BOOST) - A step by step guide for implementing Project BOOST (Better Outcomes for Older Adults through Safe Transitions). The site also offers general information about quality improvement practices.
  • Project RED (Re-Engineered Discharge) (www.bu.edu/fammed/projectred/) - Information on the key concepts and primary tools that are the foundation for the National Quality Forum's National Patient Safety Goal on safe discharge.
  • The Care Transitions Quality Improvement Support Center (www.cfmc.org/caretransitions/) - This site is oriented toward Medicare Quality Improvement Organizations (QIOs) and also contains links for patients and providers to useful resources regarding care transitions.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

SUMMARY

  • The decision whether or not a hospitalized patient is appropriate for discharge requires evaluation of multiple factors involving medical, as well as psychosocial, logistic, and economic considerations. Instruments for determining suitability for discharge that have been appropriately validated are not available. (See 'Appropriateness for discharge' above.)
  • The need for ongoing hospitalization is determined by the clinical condition and need for ongoing diagnostic or therapeutic interventions. Multiple logistic factors beyond these clinical considerations will determine if the patient is safe to be discharged home, or requires another setting. (See 'Determining the post-discharge site of care' above.)
  • Discharge planning should involve the clinical staff and patient/family caregivers to develop a patient-centered plan. Critical elements in successful discharge transitions include performing an accurate reconciliation of medications, establishing timely follow-up, and developing an appropriately detailed discharge summary that is communicated to aftercare providers in a timely fashion. (See 'Elements of the discharge process' above.)
  • Avoidable rehospitalizations may be related to therapeutic errors and failed handoffs. Identifying patients at increased risk for rehospitalization can help target interventions to minimize this risk. Identifying systems issues which contribute to failed discharge transitions may shed light on opportunities to improve the safety of the discharge process for all patients. (See 'Factors contributing to rehospitalization' above.)
  • Several systems initiatives have shown promise in minimizing rehospitalizations. These interventions include improved collaboration between the care team, patient, and aftercare provider prior to discharge; medication reconciliation; enhanced patient education and empowerment; home visits or telephone calls by clinical providers; remote monitoring; and early post-discharge follow up. Patient instructions should take into account the patient's cognitive status, health literacy, and other barriers to self-care. Multiple concurrent interventions may be more effective than single components. (See 'Discharge and post-discharge interventions' above.)

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