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The transition from hospital to home or to another care site is a high-risk period for the patient for a number of reasons, as we have discussed in The Hospitalist this year. Ineffective communication with the patient and between healthcare practitioners at discharge is common. In addition, primary care providers increasingly delegate inpatient care to hospitalists. This delegation of care can lead to gaps in knowledge that present risks to patient safety.

Further, information transfer among healthcare practitioners—whether they be primary care providers or hospitalists—and their patients is often compromised by record inaccuracies, omissions, illegibility, information never delivered, and delays in generation or transmission.

The Agency for Healthcare Research and Quality (AHRQ) has identified recall error, increased clinician workloads, interface failures between physicians and clerical staff, and inadequate training of physicians to respect the discharge process as the root causes of deficiencies in the current process of information transfer at discharge. While an interoperable health information technology infrastructure for the nation could effectively address many issues related to discharge planning, such a solution is certainly many years away.

New Approaches

Given the fact that a nationwide, interoperable health information technology infrastructure is not yet a reality, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is exploring multiple approaches for improving communication with patients and among practitioners in the discharge planning process. This article details those strategies and is meant to stimulate discussion and elicit suggestions for future approaches.

If you have any suggestions for improving the discharge planning process, e-mail us at ldionne@wiley.com. We’ll publish the most effective and intriguing responses in a future issue of The Hospitalist.

Discharge Planning Standards

Patients may be discharged from the hospital entirely or transferred to another level of care, treatment, and services; they may be reassigned to different professionals or settings for continued services. JCAHO standards require that the hospital’s processes for transfer or discharge be based on the patient’s assessed needs. To facilitate discharge or transfer, the hospital should assess the patient’s needs, plan for discharge or transfer, facilitate the discharge or transfer process, and help to ensure that continuity of care, treatment, and services is maintained.

These standards (found in the Provision of Care (PC), Ethics, Rights and Responsibilities (RI), and Management of Information (IM) chapters of the hospital accreditation manual) will be updated in July 2007. The changes include both new language and new requirements meant to improve communication with patients and among providers during the discharge planning process. Rather than a significant overhaul, these changes can be viewed as refinements to the existing standards that will help hospitals ensure that the intent of each standard is actually carried out to benefit patients. For example, an element of performance for standard PC.4.10 that addresses development of a plan of care now specifies that this process should be individualized to the patient’s needs. Another example is standard IM.6.20, for which an element of performance will require that the medical record contain medications dispensed or prescribed at discharge.

It is also important to note that JCAHO standards underscore the importance of the patient retaining information. Today, JCAHO requires—through its National Patient Safety Goals—that a list of current medications be provided to the patient at discharge. For patients who have been treated by a hospitalist, this requirement is especially important when they return to their primary care physicians for follow-up treatment.

Discharge Planning During the On-Site Survey

JCAHO began more closely examining discharge planning in 2005 by piloting a new process that surveyors used to evaluate standards compliance in 2006. The first option tested is a concurrent review in which surveyors observe the discharge instructions as they are being taught to the patient and then interview the patient about the content. The second option is a retrospective review and entails calling patients 24 to 48 hours after discharge to ascertain their understanding of the medication regimen and other instructions provided. Both options are used by JCAHO surveyors to understand how practitioners, nurses, and other caregivers carry out the hospital’s policies.

To help hospitalists understand how surveyors approach this process, the following summary provides information about the two review options.

Discharge Planning—Active Review

  1. Ask for a list of patients who will be discharged during the survey.
  2. Review the patient’s medical/clinical record for discharge orders.
  3. Request that the organization obtain patient permission to observe the discharge process.
  4. Observe the clinician providing discharge instructions. Components of the discharge instruction may include:
    • Activity;
    • Diet;
    • Medications (post-discharge);
    • Plans for physician follow-up;
    • Wound care, if applicable;
    • Signs and symptoms to be aware of (i.e., elevated temperature, medication side effects);
    • The name and telephone number of a physician to call should a problem or question arise following discharge; and
    • Patient repetition of information to confirm understanding.
  5. Review the written discharge instructions given to the patient. The discharge instructions are written in a language the patient can read and understand.
  6. Interview the patient to determine the patient’s level of understanding of discharge instructions. If applicable to the instructions given to the patient being observed, the patient should understand:
    • The purpose for taking any new medication;
    • How to take the medication, including dose and frequency;
    • Possible side effects of medication;
    • The medication regimen, including continuation or discontinuation of medications taken prior to hospital admission;
    • Contraindications between prescribed medications and over-the-counter medications and herbal remedies;
    • Changes in diet and dietary restric- tions or supplements;
    • Signs and symptoms of potential problems and who to call with questions and concerns;
    • Information regarding continued self-care (i.e., wound care, activity);
    • Follow-up process with physician(s); and
    • Arrangements made for home-health needs (i.e., oxygen therapy, physical therapy).
  7. Interview the nurse/clinician to ascertain the origination of discharge information (physician-nurse communication regarding discharge instruction).

Discharge Planning—Retrospective Review

  1. Ask for a list of patients discharged during the past 48 hours.
  2. Review the patient’s old medical record for discharge orders.
  3. Request that the organization stay with the surveyor as phone calls are made. The organization should first talk with the patient to explain the purpose of the call and obtain permission for a phone interview.
  4. Interview the patient to determine understanding of discharge instructions provided. If applicable to the instructions given to the patient being observed, the patient should understand:
    • The purpose for taking any new medication;
    • How to take the medication, including dose and frequency;
    • The medication regimen, including continuation or discontinuation of medications taken prior to hospital admission;
    • Possible side effects of medication;
    • Contraindications between prescribed medications and over-the-counter medications and herbal remedies;
    • Changes in diet and dietary restrictions or supplements;
    • Signs and symptoms of potential problems and whom to call with questions and concerns;
    • Information regarding continued self-care (i.e., wound care, activity);
    • Follow-up process with physician(s); and
    • Arrangements made for home health needs (i.e., oxygen therapy, physical therapy).
  5. Explore the patient’s perception of the discharge instructions. Does the patient believe the necessary information was given?

Continuity of Care Record

Recognizing that patients remain the primary vehicle for transporting basic health information between providers, JCAHO is exploring strategies related to the Continuity of Care Record (CCR). This approach acknowledges that electronic health records are—at this time—a goal rather than the norm. Patients typically transport basic health information between providers in the context of completing a basic set of information on a registration form that is attached to a medical clipboard, prior to outpatient appointments and admissions.

An accurate minimum data set, containing such items as medication lists, allergies, conditions, and procedures, would provide substantial value to providers and patients. JCAHO already requires that an accurate medication list be updated at discharge and made available to the patient and the subsequent provider of care, but other key pieces of patient data, such as diagnosis and procedures, as well as the means required to make these data available to the patient or to the next caregiver, are not currently required.

JCAHO is now considering how hospitals and other healthcare organizations could provide or update a clinically relevant minimum data set of summarized health information, such as that contained in the CCR. The CCR is a standard specification being developed jointly by ASTM International, the Massachusetts Medical Society, the Healthcare Information Management Systems Society (HIMSS), the American Academy of Family Physicians, and the American Academy of Pediatrics.

JCAHO envisions a minimum data set that includes an accurate list of demographics, medical insurance, medications, diagnosis, past procedures, allergies, and current healthcare providers. It also desires a data set that can be provided to the patient or the patient’s authorized representatives—both as paper and in a fully transportable and interoperable digital format—that could be presented to subsequent caregivers. This summary health record would permit care providers within or outside the organization to review the patient’s important clinical information at the point of care and near the time of clinical decision-making. Subsequent care providers would then be able to update the patient’s minimum data set as appropriate.

In addition to providing caregivers with the most essential and relevant information necessary to ensure safe, quality care, such an approach would minimize the effort necessary to keep such information current. Healthcare providers would have easy access to the most recent patient assessment and the recommendations of the caregiver who last treated the patient.

Patient Involvement

JCAHO has sought to help healthcare organizations in assisting patients with the discharge planning process through its Speak Up education program, which urges people to take an active role in their own healthcare. “Planning Your Recovery” provides tips to help people get more involved in their care and obtain the information they need for the best possible recovery. Patients who understand and follow directions about their follow-up care have a greater chance of getting better faster; they are also less likely to go back to the hospital.

Specifically, the JCAHO education campaign advises patients to:

1. Find out about their condition. This includes knowing how soon they should feel better, getting information about their ability to do everyday activities such as walking or preparing meals, knowing warning signs and symptoms to watch for, enlisting the help of a family member of friend in the discharge process from the hospital, and getting the phone number of a person to call at the hospital if a problem arises.

2. Find out about new medicines. It is important to request written directions about new medicines and ask any questions before leaving the hospital. Other issues that JCAHO advises patients to consider include finding out whether other medicines, vitamins, and herbs could interfere with the new drugs and knowing whether there are any specific foods or drinks to avoid. Understanding the side effects of medications and any necessary restrictions on daily activities because of the potential for dizziness or sleepiness is also crucial.

3. Find out about follow-up care. This includes asking for written directions about cleaning and bandaging wounds, using special equipment, or doing any required exercises; finding out about follow-up visits to the hospital and making transportation arrangements for those visits; reviewing insurance to find out whether the cost of medicines and equipment needed for recovery will be covered; and determining whether home care services or a nursing home or assisted living center will be necessary for follow-up care.

JCAHO is joined in encouraging people to play an active role in planning their recovery by the National Alliance for Caregiving and the Centers for Medicare and Medicaid Services’ Care Planner. Practitioners who want to share this advice with their patients or wish to direct their patients to the information can go to JCAHO’s Web site, www.jointcommission.org, to download a free Speak Up brochure.

Conclusion

Ideally, discharge planning should be a smooth process facilitated by a personal health record that is controlled by the patient and that provides ready access to all of the patient’s health data that have been compiled from all the patient’s healthcare providers. Such a record would be accessible anywhere and at any time, over a lifetime. This concept remains in its infancy, however. Until such time as communication with patients and among providers is more transparent and less prone to error, The Joint Commission will continue to seek methods to better address this important aspect of providing safe, effective care. TH

Dr. Jacott, special advisor for professional relations at JCAHO, is the organization’s liaison to SHM. He also reaches out to state and specialty physician societies, hospital medical staffs, and other professional organizations.

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