Transitions of Care: Tips for Safe Discharges

Christine Hamilton

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• 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