Guest Column

Get a handle on your discharge process

Engagement of all relevant disciplines is necessary

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Hospital discharge must be viewed as a process rather than an event — which should start as early as possible, i.e., at the point of admission if not before. Case managers should identify the patients who are likely to need an actively managed hospital stay and post-hospital health and social care services. Where there is a potential for long-term support or skilled care, systems must be set up as soon as possible to ensure a smooth transition at the time of hospital discharge. Good patient assessment and discharge planning depends on a mixture of different professional skills. This requires engagement of all the relevant disciplines, e.g., therapists, nurses, social workers, physicians, as well as the patient and their relatives.

Effective partnership among all members of the health care team is the foundation of good care coordination practice for hospitalized patients. How well hospital discharges are managed is a good litmus test of how the different parts of the whole system work together. The problems concerning hospital discharge fall into a number of categories; these include discharges that:

  • occur too soon;
  • are delayed;
  • are poorly managed from the patient/family perspective;
  • are to potentially unsafe environments.

Insufficient capacity within local residential and nursing homes is cited as a common reason for hospital discharge delays. The hospital must work with local agencies to consider what is needed in the community and project future needs. Engagement of community leaders and providers should be actively pursued. More capacity may not necessarily mean "more of the same." Reimbursement policies make it clear that an acute care hospital is not the best place for an older person while further assessment or services are put in place. Health care capacity plans for the community should include interim, nonacute care options for these patients. Fundamental rebalancing of existing services toward rehabilitation and promoting independence may be needed.

Another common reason for discharge delays occurs where placements of choice are not immediately available. Remaining in the hospital until the desired placement becomes available is not appropriate. The definition of choice must be qualified by choice of what is suitable and also available. Finally, managing capacity is not simply about beds or buildings. For example, delays in carrying out patient assessments can arise when appropriate staff are not available at the right time or with the right skill mix. Discharge delays also can occur when services such as transport, home medical equipment delivery, pharmacies, or diagnostics are not available at evenings and weekends.

Effective partnership among all members of the health care team is the foundation of good care coordination practice for hospitalized patients. How well hospital discharges are managed is a good litmus test of how the different parts of the whole system work together.

To understand the impact of proactive discharge planning, it is essential that each unit monitor relevant performance indicators. For example:

  • average length of stay;
  • percent of patients discharged on their predicted day of discharge;
  • discharge patterns by day of week and time of day;
  • percent of patients seen by a case manager;
  • percent of patients discharged by 11 a.m. (or recommended discharge time established by the hospital);
  • number and type of patient complaints about the discharge process;
  • number and type of delayed discharges.

Having the right processes in place to accurately record the number of discharge delays and the reasons why they occur is an essential first step to tackling the causes of delays. It is not possible to resolve problems if the reasons for delays are not well understood. Don't just report the number of discharge delays. The information needs to be broken down into meaningful categories. Also, the data must be as accurate as possible so that energy is directed at tackling the problems, not disputing the figures. Categories for reporting discharge delays include:

  • internal hospital factors (e.g., the timing of patient rounds; waits for diagnostic test results; delays in a home assessment);
  • coordination issues (e.g., communication and arrangement of health and other community-based services, availability of transportation);
  • capacity and resource issues (e.g., limited availability of care options; placement difficulties at post-discharge care facilities; availability of a home care provider);
  • patient/family involvement/choice (e.g., lack of engagement with patients and family members in decisions about their care; patient/family refusal to accept post-discharge recommendations).

Vulnerable or elderly patients often have continuing care needs after being discharged from acute hospital care in order to resume independent life at home. Successful transition from hospital to home requires good discharge planning, with collaboration between the hospital, relatives, and community health services. A measure of collaboration could be "hospital bed days lost due to delayed discharge" — the higher the figure, the poorer the collaboration. An indicator of good discharge and appropriate rehabilitation could be "percentage of patients admitted from their home who return to their own home."

Feedback from patients and family members also can serve as a valuable measure of discharge planning performance. To be useful for performance improvement purposes, this feedback must provide sufficient detail about the patient's experience. One question about discharge planning on a multi-question patient satisfaction survey is not adequate. If you ask patients to rate their satisfaction, you tend to get very positive responses, despite the fact that you know things aren't perfect. In addition to surveys, it is helpful to gather more information through focus groups and face-to-face interviews.

Below are examples of questions that would provide greater depth of information about what happened during the discharge process from the patient's perspective:

• Were you (or your family) personally involved in making plans for your discharge?

• How satisfied were you with preparations for your discharge?

• Did you receive adequate discharge assistance from hospital staff?

• If you did not return home when you were discharged,

— were you (and your family) given a say in where you would go after leaving the hospital?

— prior to you leaving the hospital, did your family (or nonfamily caregiver) visit the place where you would be going?

• When you were discharged, did you know the name of the physician or other health care professional who would be caring for you after leaving the hospital?

• When you were discharged, were all arrangements finalized for any treatments or care you would need after leaving the hospital?

• When you first saw your physician (or other health care professional) after leaving the hospital, did he or she have enough information about your hospital stay to be able to care for you properly?

Successful discharge planning is not achieved by finding a single silver bullet. Realizing an effective patient discharge process involves a series of small, incremental improvements in clinical, operational, and strategic planning aspects that accumulate to have an impact on the efficient transfer of patients from one setting of care to another. Use the checklist in the Figure to evaluate your current process. The "no" answers represent improvement opportunities.