Discharge from the hospital is a critical point in a patient’s recovery, especially for older people who suffer from chronic conditions like heart disease. Making sure a patient and their primary caregivers are ready for the return home is crucial.

According to a 2009 study published in the New England Journal of Medicine, around 20 percent of hospitalized Medicare patients — that’s about 1 in 5 — are readmitted to the hospital within 30 days of their discharge. The cost of this revolving door care? Approximately $17 billion annually.

Discharge planning is a systematic, organized and centralized approach to providing continuity of care from the time a patient is admitted to the hospital through their return to the community/home.

“Effective preparation for transition to the next level of care is the key to ensuring safe patient discharge and averting early readmissions,” said Bill Assibey, RN, MBA, director of Case Management at Scott & White Healthcare. He explained that every patient has a discharge plan created for them upon admission to the hospital. “Several factors for consideration include, but are not limited to, psychosocial, physical and clinical circumstances. That helps determine the discharge plan,” he added.

Assibey cites the two biggest reasons patients are readmitted to the hospital are medication noncompliance and lack of follow up care/physician appointments.

Scott & White recently implemented a “care transitions initiative” aimed at eliminating the need for a quick return to the hospital after discharge. Case managers — trained social workers — visit with and speak to the patient via telephone within 48 hours of discharge to review medication instructions, discuss symptoms or signs that might indicate if they should return to the hospital or visit their physician, and confirmation that the patient has indeed followed through on their discharge instructions. While still in its early stages, the program is showing promising results.

So how can you make sure you or a loved one is ready for discharge? Assibey suggests that both patients and their caregivers ask the following questions and fully understand the answers provided:

• What are the signs/symptoms I should look for that might indicate the need for additional medical care? At what point do I call my physician or go to the Emergency Department?
• What medications do I need to take and what are the dosages and schedules? How do I fill my prescriptions? What are the signs and symptoms of adverse reactions to any of these medications?
• What special equipment might be required to help in my recovery? How do I obtain it?
• How do I perform certain tasks (such as wound care or transferring a patient from the bed to a chair)?
• When do I need to see my physician again?

“Probably one of the biggest shortfalls of discharge planning is when the patient or family do not understand the instructions they have been given,” Assibey said. “It is critical for the family/patient to be included in the patient’s care decisions and the plan of care and encouraged to be very involved once they leave the hospital. Case managers can provide the family/patient with the resources necessary to better understand and meet the needs of the patient.”

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