Fixing hospital discharge processes

Moving a sick person from one setting of care to another is fraught with challenges and errors.  Some have estimated that the average hospital discharge includes at least one serious potential harm.  The risks of moving around in the care system have increased in recent years because of the increasing segmentation of service providers.  No longer does the usual patient have the same physician in all settings – now the hospitalist service manages the hospitalization, the nursing home team takes over in that setting, and the outpatient physician gets the patient back with no more than a one-page summary.  The usual patient has become much more complicated also.  Fifty years ago, few people lived long with advanced heart disease, for example.  Now, many people spend many years depending upon a complicated balance of multiple medications, structured diets, and other treatments, all of which regularly undergoes upheaval with a change in illness and setting of care.

A current project of the Centers for Medicare and Medicaid Services, the Care Transitions Theme for the Quality Improvement Organizations, is among the initiatives that have taken on improving transitions in the care system.  A summary of that project, along with a table of the research-proven strategies for improvement, is at  The 14 communities involved in Care Transitions are learning a great deal about what works, how to adapt the research findings, and how to generate workable coalitions.  In addition, the project has had talks and powerpoint presentations from virtually everyone working on improving care transitions in the country, and they are all available at

Most of the leading research and implementation endeavors have user-friendly websites:
Some of the interventions that proved effective in improving transitions were:
  • Simply having the “senders” and “receivers” get to know one another. From one site visit: “Can you imagine that just one year ago, I would send a patient off to the SNF with whatever I could throw together and count on luck for it to work out.  Now that I know the people there, I could never do that.  We make sure they have what they will need. Every single discharge gets the information faxed and then a follow-up call to answer any questions before the patient leaves here.”
  • SBAR (structured Situation, Background, Assessment, and Recommendation) communication from nursing homes to on-call physicians, including advance care plans such as POLST, thereby teaching even unfamiliar physicians more about what the nursing home could do  See the INTERACT II website as an example
  • Teachback – a technique that has the learner (the patient or family caregiver) tell the teacher (the nurse or doctor, for example) what they have learned from the interchange.  This gives the teacher the immediate opportunity to reinforce or modify what was learned and greatly adds to the retention and usefulness of learning, e.g., about medications or self-monitoring.
  • Exchange visits to upstream and downstream provider sites, either for a meeting and tour or for a whole day.  The longer visits clearly generated more mutual respect for the tasks facing one’s peers in another setting. From a site visit: “Hospital staff members were surprised to find how resource-limited the SNFs were, while the SNF visitors were impressed with the caseload and time pressure on the hospital staff.”  From another hospital-based visitor to SNF: “It is hard to imagine how they do it with no nurse educators, no computers, no specialists – often no doctors around!”
  • Structured information transfer
  • Electronic information transfer – However, the “receiver” in a transfer has to be able to use electronic information.  One hospital put together a good package of electronic information to send to their SNFs without realizing that the clinical nursing team had no access to computers.  
  • No transfer without notification, with oral or faxed “ok”
  • Study of reasons for readmission
  • Meetings of upstream and downstream providers
  • Process maps across settings, jointly produced and critiqued (done every six months by St Mary’s Hospital in Grand Junction, CO – hyperlink to Health Affairs article)
  • Medication reconciliation, though this turns out to have many complexities.  See Too many med lists as an example.
  • Trigger tool for palliative care
  • Targeting tool to identify higher risk patients and provide care management
  • Volunteers to provide coaching – worked well in some settings and not at all in others – seemed to depend upon finding older, mature volunteers who enjoyed having acceptance by hospital staff, rather than college students on a short-term assignment.  Can require training in standard clinical practices like infection control and privacy.
  • Data from direct measurement as to how well the discharge process is working
  • Recognition that the community system will function much less well if certain elements, mostly those serving the poor, are not sustained; and therefore, sending only the patients with the most complicated and underfinanced needs to those providers may put them out of business and thereby worsen both the community health and the demands on other providers.
  • Hospitals sometimes helped SNFs to use electronic data, providing training and sometimes even computers.  In at least one case, the hospital expects to repeat the training every six months, in anticipation of the usual nursing home staff turnover.
  • Getting appointments in the 4-7 day time frame that is usually optimal after a hospital discharge requires cooperation from the physician office.  In one system, the Care Transitions QIO worked with the office managers to be sure they understood why this was important and how to achieve it (using principles of flow to achieve same-or-next-day service in offices generally), and got post-hospital appointments routinely available. (check for resource on
  • Getting more routine rounds by nurse practitioners or physicians at skilled nursing facilities, so that discharged patients or newly more ill residents can count on being seen promptly.
  • Expanding the scope of what SNFs are able and willing to do – e.g., to give furosemide IV and check on outcome before sending a fluid-overloaded person to the hospital.
  • Palliative care – e.g., more advance care planning in all sites, more symptom management, more palliative care teams, more referrals to hospice.
  • Getting multi-facility accord on “do not resuscitate” orders so that they are not routinely abrogated with each transfer (and require being re-discussed before being reinstated).  State adoption of POLST is helping this situation, in that the POLST is usually honored in all settings.  In the absence of such a state-level accord, local agreements between emergency medical transport, hospitals, and nursing homes (at least) are plausible.
  • Encourage arrangements in which a physician who provides care for multiple very sick persons living in the community can work mostly with a home health agency team, so that all parties get to know one another and can communicate efficiently and frequently.  The referral patterns in some communities are ensuring that such a physician will have virtually as many home health care teams as he or she has patients needing those services, which makes it very hard to coordinate services and provide support.
  • Be thoughtful about improving referral patterns that send only difficult and expensive patients to the one or two “non-profit” home care or nursing home providers in the community.  Without some other means of support, those providers are going to have substantial disadvantages and may not be able to continue.
  • Make sure that the nursing home or home care nurse who calls the emergency room to give a report on a patient coming to the ER is treated with priority and respect.  Multiple teams found that such a call-in was routinely handled by a non-clinical clerk and the information was not promptly put into the ER chart.  Moving such a call to the clinical team and giving it in SBAR format greatly improved communication.
  • Be sure that email addresses, fax numbers, and text message destinations are kept current.  One hospital found, when doing a marketing mailing, that only 19% of the fax numbers for their community physicians were correct.  No wonder the physicians claimed not to have received the discharge summaries!  Usually about half of addresses become incorrect within two years, so a method of checking and updating will need to be built into any electronic communication system.  
  • Patients and families refusing offered services can complicate efforts to reduce the trauma of transition.  Methods to reduce refusals and to provide back-ups that are acceptable are still needed.
  • Transitions are often considered only in well-travelled patterns: home or nursing home to hospital, and hospital to nursing home, for example.  Some teams found substantial opportunity in deliberately considering other possibilities: ER to hospice, or home health agency to nursing facility for respite care.  One team realized that 75% of home care enrollments in a nearby community came straight from home, often thereby avoiding the ER and hospitalization. 
  • Participants often really enjoy this work – they like the networking, the improvement in patient care, and the opportunity to get “beyond whining” about the situation.  In many cases, this was the enduring fuel for ongoing work.
  • One hospital has arranged to put a list of key discharge information on a secure website.  The discharging physician sends a text to the outpatient physician to say that the information concerning a particular patient is there, and then gets a text message back to confirm.  Until the return message comes back, the responsibility stays with the discharging physician, so having no confirmation leads to a phone call.
  • Most of the teams generated some sort of patient-controlled record, usually in hard copy (though the one site with many patients having personal health records on-line used that resource also).  These were usually about the size of 4 pieces of paper folded in half, and some were produced informally and others printed in style.  These were given to complicated patients and kept up by all providers that they were using.  Patients picked up on this well, and some sites had very high rates of use.  Indeed, one problem was that patients were sometimes getting multiple such handbooks for their personal use (e.g, one from the hospital, one from their primary provider, one from their nursing home, and one from their cardiologist).  Getting the patient health records back to one version was requiring another step of standardization and the ability to rebrand an item that had become a point of pride (and marketing) for the provider.
  • Some patients end up with overlapping, inefficient services – coaching from a Care Transitions initiative, CHF follow up by phone from a CV nurse, and also home health agency in-home follow up teaching.  At the least the messages need to be standardized, and in addition, the work probably needs to be streamlined.
  • The “Four Pillars” of the Coleman Care Transitions ( approach are in use in many settings that are not using the whole transitions coaching model.  It seems to be a simple way to list and remember critical elements of transitions: 
    • Medication self-management, 
    • Personal Health Record, 
    • timely physician follow-up, and 
    • knowing the “red flags” that something is going wrong and how to respond. 
  • Estimating the patient activation level using a quick interview tool helps target the teaching for self-care to the right receptivity and to help enable the patient to take more of a role.  In one Care Transitions site, nearly everyone is brought up to a good level of self-care within a month of hospital discharge. 
  • Getting multiple parties to agree that they each, individually and collectively, “own” the problems that arise during transitions – and each one has responsibility not only for their own process but for the meshing with the processes ahead and after theirs.  The usual situation is that no one “owns” the period of transfer. One nurse said early in one of the Care Transitions initiatives: “We aren’t responsible for them [patients] once they leave!”
  • Many improvements are “one person thick,” at least for the first months, so that illness or changes in that person’s job can send a good idea off track.  It is important for the process to be known and owned by multiple persons very quickly.
  • Hospital-based clinicians often see the hospital period as the defining element of the course, and post-hospital care is meant to shore up the gains.  Outpatient clinicians (and usually the patient and family) see the hospital period as one of many elements that mark the course of living with chronic illness – so there is ALWAYS a need for follow-up and ongoing care.
  • For nursing home residents, discussions of limiting hospitalization and resuscitation are often difficult until the resident has been back in the hospital once – and then the hazards of hospitalization are so much more evident that resident and family are more willing to consider staying on-site for most complications. 
  • The coalitions regularly called for uniform assessment methods, so that patient assessments would be able to be followed across settings of care.  Some of the teams were developing their own, and some proceeded to use elements from the CARE instrument, even though CMS had withdrawn it partway into the project.
  • Coaching and nurse visits are very expensive elements and not readily done by volunteers or as part of an existing job, so they probably need to be targeted to higher risk, and higher gain, patients.
  • In one hospital, the hospitalist on one floor does rounds with the multi-disciplinary team and the patients and families at the same time every day.  The effect upon rehospitalization was substantial, even though that was not the initial aim.
  • Many fee-for-service physicians do not know the possibilities for billing for services such as reviewing the plan of care with the home care nurse, or having a family meeting with the patient to settle a plan of care.
  • Very sick patients often do not learn most of what they are taught – the teaching about self-care usually has to be reinforced once they are home.
  • Self-care can be supported with written materials and with videos.  One provider has arranged for the instructional videos to be played on the local cable, so patients can watch them at home.  Thus, a physician can write a prescription for the patient to view these videos.
  • Medicare Part D plans vary substantially in formulary, so that often dictates a change in medication or at least its appearance at discharge.  These changes confuse patients and families.
  • High rates of readmission afflict dialysis patients, so working with dialysis centers to manage medical issues early seems likely to reduce hospitalizations, complications, and mortality.
  • Dyspnea when dying  is a major cause of moving a person from community or nursing home to the emergency room.  Many physicians are wary of ever using opioid medications in this setting.  Only the hospice programs have much skill and familiarity, and even they are not always reliable.  So, short-of-breath patients who are not yet in hospice have no real alternative to the ER, and then usually to intubation.  A focus on dealing with dyspnea near death without needing hospitalization would reduce pressures to hospitalize.
  • Mapping the process of discharge, transfer, and resettling between the provider partners has been a reliable way to notice problems and get teams focused.  Especially when the discussion turns to mention of specific recent patients who shared these providers, the salience of the work becomes clear.
  • One team contracted for coaching, thus creating a potential line of work for a consulting business.  Others provided coaches within their budget, and some got the providers to establish some coaches if they wanted to pursue the Coleman model.  The disparate impact on budgets is reflected in what else the QIOs could do.
  • One Care Transitions team identified patients at nutritional risk during their coaching and the Department of Elder Affairs for the state and the Area Agency on Aging provided 10 supplemental meals when the person first went home.
  • Many hospitals and sometimes other providers have onerous processes for approving forms that go into medical charts – often lasting a year.  This makes it important to make changes that do not require changing forms!
  • Two Care Transitions teams pointed out that patients have “the right to fail” – that is, they can choose to go home without adequate support, even in a risky situation. 
See also The Medicare Transitions Experience.