Case managers may not be in charge of all their patients’ discharge education, but it is their responsibility to make sure that patients receive the education they need to care for themselves at home and that they understand it, or that referrals are made after discharge to continue their education, says Linda Sallee, RN, MS, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago.

“Case managers need to make sure patients have a follow-up phone call and the name and number of someone to contact if they have questions, can’t get their medication, or have symptoms,” Sallee says.

The entire staff has to engage the patient in preparing for discharge, says Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan Health Group, a Newton, MA-based healthcare transition management software firm. Case managers should make the rest of the healthcare team aware of the impact it has on patients when you just hand them discharge instructions as they prepare to go home, she adds.

“Thanks to the Star Ratings, we now have evidence that almost half of patients don’t understand. The hospital staff often doesn’t understand the business end of the hospital. They may not know about HCAHPS, their hospital’s scores, and what they mean. Case managers must be educators on the nursing unit about the HCAHPS and patient education,” Birmingham says.

Discharge teaching isn’t effective if it’s done right at discharge, says Eric Heil, co-founder and chief executive officer at RightCare, a healthcare information technology company based in Horsham, PA.

Instead of trying to teach patients what they need to do to care for themselves at home at the end of the stay when they are eager to go home or anxious about going home, start the conversation early in the stay, or before the stay if it’s an elective procedure, he recommends.

This means that case managers need to identify patients who will need extensive instructions at admission, alert the nursing staff, and to work with the patients throughout the stay to prepare them for discharge, he adds.

Heil suggests breaking the discharge teaching down into short segments and giving patients written instructions to study while they are in the hospital so they will have time to ask questions.

Make sure you’re talking about whoever is going to care for the patient once he or she gets home, Sallee says. Make sure the written discharge information has a place for patients to write questions so they’ll be prepared when they get a follow-up phone call or see their physician. Include information on who to contact if they have questions about their care or if services such as home health or durable medical equipment don’t show up, Sallee adds.

Develop a relationship with patients early in the hospital stay and repeatedly reinforce the discharge information, says Toni Cesta, RN, PhD, FAAN, partner and consultant in Dallas-based Case Management Concepts.

Go into patients’ rooms, sit down, and look like you have time to talk, she suggests. Discuss the importance of taking their medication as instructed and make sure they have a way to get prescriptions filled and can afford to pay for the medication, she says.

When patients report on the HCAHPS that they weren’t told about their discharge medications, it comes back to healthcare professionals’ inability to communicate with patients, Cesta says.

Educate your patients on the importance of scheduling a follow-up visit with their doctor after discharge and make sure they have a timely appointment and a way to get there, Cesta says.

When patients are going to have home health services, prepare them about what to expect, says Wanda Pell, MHA, BSN, director of Novia Strategies, a national healthcare consulting firm.

“Some patients think ‘home health services’ means somebody is going to be in the home taking care of them 24/7. They are disappointed and unhappy when they find out differently. Properly setting the patient’s and family’s expectations is paramount,” she adds.

Heil has worked with hospitals that allow the home health nurse who will be seeing the patient after discharge visit in the hospital. “This way, the patient won’t be opening the door to a stranger. Establishing a relationship before discharge can make a huge difference,” he adds.

Call patients after discharge to check on how they’re doing and to make sure they have filled their prescriptions and have an appointment with a physician, Cesta says.

Patients’ healthcare literacy plays a significant role in their responses to the HCAHPS questions, says John Zelem, MD, FACS, vice president, compliance and physician education at Executive Health Resources, a Newtown Square, PA, consulting firm.

“If there is a language barrier or they don’t understand their discharge instructions because they are too technical, it can be reflected in their answers to the HCAHPS,” Zelem says.

Give your discharge instructions in simple English or, in the case of patients who aren’t fluent in English, in the language they prefer. Give them materials that are concise and easy to read to supplement what you are telling them. Use the teach-back method to make sure they understand.

Case managers need to stop thinking about a “discharge plan” and start thinking about a “transition plan,” Sallee says.

“It’s no longer about just getting a patient out of the hospital and back home or to a skilled nursing facility. It’s about helping the patient transition to the next level of care with all the resources needed,” she says.