Six steps lead to better transitions
Facilities implement them the way that works best
After interviewing hundreds of patients and family members, a multi-disciplinary team at Kaiser Permanente redesigned the process for transitioning patients from the hospital to home and developed a list of six processes that should happen during every discharge for every patient.
"As each facility implements the transitions-in-care procedures, they do it in the way that works best for them, but all their transition plans include the same bundle of processes," says Carol Barnes, MS, PT, GCS, executive consultant for strategic programs, CARE Management Institute, Kaiser Permanente, Oakland, who facilitated the transition improvement project.
Based on the responses from patients and family members, the team identified six elements to improve the patient experience during the discharge process.
A dedicated phone line for discharged patients:
For instance, one patient told the team that shortly after he got home, he wasn't feeling well and wondered what he should do. He looked through the thick packet of discharge information and the only telephone number he could find was 911. Then he looked up the facility's number in the phone book and was routed through a long voicemail tree and never connected with a person. He tried finding the number online and finally gave up and called 911.
"Our team heard similar stories from other patients and realized that patients leaving the hospital are vulnerable and need a number where they can reach someone right away," she says.
The team recommended that discharge instructions include a dedicated phone number for newly discharged patients so they can get answers to their questions and concerns immediately. The line is answered by a nurse who has access to the patient's medical record and discharge information and who is backed up by the physician team.
Follow-up calls after discharge:
"Patients told us that having someone to check on them after discharge is important," Barnes says.
For instance, a patient reported that he gets a call from the veterinarian after his cat receives treatment and that the dentist follows up after all procedures, but nobody from the hospital called to check on him after open heart surgery.
With the new process, all patients leaving the hospital get a call from a nurse within 48 hours. If patients are high risk, a nurse creates a personalized plan of care and follows them by phone for 30 days at intervals that depend on patient needs. In the Northwest Region of Kaiser Permanente, complex care nurses in the primary care offices make the calls. In other regions, it may be the hospital nurse or the emergency department physician.
Follow-up primary care appointments:
Some patients told the interviewers that when they got home, they didn't realize they needed to make a follow-up appointment with their primary care physician.
"I'm sure the nurses or doctors told me, but I was on a lot of medications in the hospital and I don't remember much about what they said," one patient reported.
Now, the hospital team makes a follow-up appointment while the patient is still in the hospital and includes the information in the discharge plan.
Since almost half of the patients who were readmitted came back within the first week, the team makes sure everybody gets an appointment within a week and that high-risk patients see their primary care doctor for follow up within two to three days.
Redesigned medication management:
"Some patients told us they often don't understand why their medications changed and what they were supposed to do when they got home," Barnes says. "Medication management is really important and the hospital may not be the best place for patients to learn."
The team developed a process for medication management across settings. A pharmacist reviews the medications for at-risk patients while they are in the hospital and calls the patients after discharge to go over the medications. The nurse who makes follow-up calls goes over the medication regimen. "Medication management is the number-one place where we find problems during the follow-up calls," she says.
In addition, the team recommended a system to ensure that medications are reconciled when patients come into the hospital. "The new system has reduced medication errors," she says.
Standardized discharge assessments:
Some patients reported that they didn't have confidence that the system knew what they needed at home. "One caregiver told us that the treatment team educated his wife on what she was supposed to do after discharge but that the wife has dementia and didn't understand," she says.
The redesign team recommended standardized assessments throughout the hospital. Physicians stratify all patients for risk of readmission based on their physical condition. The discharge planning nurses also stratify patients based on their home situation and psychosocial needs. The information is based on the discharge summary, alerting the primary care physician, the home health nurse, and post-acute facilities of the patient's risk.
Patients at high risk get tailored discharge planning and education and frequent follow up calls.
Improved communication with primary care physicians:
Some patients reported that sometimes their primary care physicians weren't aware that they had been hospitalized. The primary care physicians reported that often they didn't get discharge information and that when they did it was either a lengthy document or just one line.
The team developed a simple, standardized discharge summary that hospital physicians create and transmit the day the patient leaves the hospital. The document, which is integrated into the patient's medical record, has a place at the top where the physicians can write key information.
The nurses who answer the special post-discharge phone number can access the information. In addition, it's transmitted to home health nurses who use it to coordinate the patient's care.
After interviewing hundreds of patients and family members, a multi-disciplinary team at Kaiser Permanente redesigned the process for transitioning patients from the hospital to home and developed a list of six processes that should happen during every discharge for every patient.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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