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Transitions of Care: Tips for Safe Discharges

Christine Hamilton

  • Discharge from hospital represents a period of vulnerability for patients. Medical errors (especially medication errors) following discharge are exceedingly common and can lead to adverse events

On Admission:

  • Admission checklist: verify PCP, primary specialty providers, social support, current living situation, and functional status at the time of admission
  • Track any new meds, held/stopped meds, and med dose changes from the beginning
  • Consult PT/OT early for anyone who you anticipate may need home health services or need to be discharged to any location besides home

During hospitalization:

  • Consider barriers to discharge daily and discuss on rounds
  • Discuss barriers to discharge, anticipated discharge destination, and any other needs in huddle
  • Track any incidental findings or things for PCP to follow-up (e.g., incidental nodules on scans: use .vnincidental)
  • Discuss expected discharge timing daily with patient and family if possible, to set expectations

On discharge day:

  • Communicate with patient's outpatient team (e.g. PCP)
    • Typically achieved through the discharge summary
      • Include a list of specific, actionable follow-up tasks and assign a responsible party. Place in easy-to-view spot at the top of the summary
        • E.g., Instead of writing "follow-up BMP after initiation of furosemide," write "PCP to check BMP in 2 weeks after initiation of furosemide"
        • Include any pending studies and appointments from hospital admission
      • All relevant parties should receive a copy of the discharge summary (see appendices section for mechanics of discharge process)
        • It is useful to send patient with a printed copy of the discharge summary if they will follow-up outside VUMC
    • For high-risk discharges (poor health literacy, hx of being lost to follow-up, follow up outside VUMC), consider calling PCP's office to set follow-up
  • Complete an accurate and thorough medication reconciliation
    • An accurate discharge medication list depends on having a complete admission medication reconciliation (utilize pharmacy consult!)
      • Three steps to medication reconciliation:
        • Verification: Performing a Best Possible Medication History
        • Clarification: Checking that medications and doses are appropriate
        • Reconciliation: Record all medication changes
      • Seek to use at least two sources of information
      • Keep a list of any held or changed medications in your hospital course. Medication changes can be lost when not communicated during team transitions
      • Review medication changes on rounds and with pharmacist on day of discharge (bonus points for day prior to discharge)
    • Highlight any significant medication changes on discharge summary
      • Can include as follow-up tasks if pertinent (ex: PCP to follow-up BP in 2 weeks. Losartan held on d/c due to AKI but anticipate need to reinitiate once Cr normalizes)
    • Be sure to communicate any changes with the patient and/or caregiver
  • Ensure that appropriate resources and follow-up appointments have been requested* (PT/OT, skilled or non-skilled nursing HH, PCP follow-up, etc.)
  • Effectively communicate discharge plan to patient
    • Discuss medication changes, tasks for patient to complete, follow-up appointments
      • Key points should also be written in the patient instructions box
      • Useful to include educational sheets in the AVS (searchable in discharge navigator)
      • Utilize the teach-back method to ensure your instructions were effectively communicated
  • At VUMC we are fortunate to have the Discharge Care Center
    • Multidisciplinary team including nurses, social workers, care coordinators, and pharmacists
    • Phone number is included on discharge paperwork, and patients can contact them 24/7. The DCC also reaches out to patients through an automated system