Special Report: Improving care transition communication

Study shows issues with discharge instructions

Written instructions can be illegible, unclear

Patients and their caregivers sometimes have difficulty recalling details of their discharge instructions, a new study finds.1

Family caregivers recalled hearing very little information about the patient's hospital discharge, the study finds.

"I think that was frustrating to them at times," says Janice B. Foust, PhD, RN, an assistant professor in the College of Nursing and Health Science at the University of Massachusetts Boston and a nurse research associate at the Visiting Nurse Service in New York.

Communicating with informal caregivers is difficult from the hospital staff's perspective because there often are multiple people involved, Foust notes.

There are practical implications, such as trying to determine who the true caregiver is. Sometimes discharge staff will give instructions to the person visiting the patient at that moment, but this might not be the caregiver who will be helping the patient carry out the discharge plan.

"Find out who will work closely with the patient at discharge," Foust says.

"It's an important step to ask patients who else they would like to be involved in discharge planning and who else should know about this information," she says. "There needs to be collaboration with patients because it's their health, and they should give permission as to who should receive these discharge instructions."

Foust's research has found that home health agencies also report significant issues with how hospital discharge instructions are handled. Home health clinicians commented on problems with illegible instructions, incomplete instructions, and missing instructions.1

"The earlier the home care agency is involved in the care, the better," Foust says. "If they are involved while the patient still is hospitalized then it likely is of benefit and will make for a smoother transition."

Home health clinicians are a valuable resource and support for patients, and they should be more proactively included in the hospital discharge process, she says.

Conversations between the hospital's discharge team and the home health team can be enormously beneficial to patients and improve the care transition, Foust adds.

"Home health clinicians observed that sometimes discharge instructions get set aside once a patient is at home," Foust says. "Hospitals could make the instructions easier to stand out, maybe with a bright color."

Also, hospitals could follow-up the written instructions with podcasts or other educational support for patients and caregivers.

When there are written instructions, it's important the writing is legible so the home health clinician can easily read and understand them, Foust suggests.

"Home health clinicians sometimes noted that families could use more support and preparation," she adds.

It also would be helpful if hospitals provided patients with a more detailed action plan at discharge, Foust says.

"This would help home health clinicians know who to contact when there's a finding, an early sign or symptom," she adds. "Home health agencies have policies in place about how to contact the hospital, but the hospital discharge instructions could reinforce what is of concern and how and when to contact them."

These strategies might help to prevent hospital readmissions, and they reinforce the collaboration between the home care agency and the hospital.

"I think the home health agency can be a tremendously important part of somebody's post-hospital transition," Foust says. "When we speak specifically to transitions from hospitals and as people are recovering, home health is a valuable resource and can provide support for people who need to recover at home."


1. Foust JB, Vuckovic N, Henriquez E. Hospital to home health care transition: patient, caregiver, and clinician perspectives. West J Nurs Res. 2011;[Epub before print.]


• Janice B. Foust, PhD, RN, Assistant Professor, College of Nursing and Health Science, University of Massachusetts Boston, 100 Morrissey Blvd., Boston, MA 02125. Telephone: (617) 287-7535.