Critical Path Network

Communication ensures patients are safe post-discharge

Provide timely information to next level of care

Whether patients are being discharged from the hospital to home, another level of care, or transferred to the care of another health care provider, communication is crucial to ensure a safe discharge or transition, says Hussein Tahan, DNSc, MSN, RN, CNA, executive director, international health services at New York Presbyterian Hospital in New York City.

"Good communication among all the parties involved in patient care within and outside of the hospital is a key component to ensuring a smooth and safe transition of care. Case managers need to make sure that communication is effective, whether it's between members of the treatment team, the patient and family or caregiver, the payer, or anyone else who is involved directly or indirectly in the care of the patient," he says.

Any communications between the hospital and clinicians or caregivers at other levels of care also should be documented in the medical record, Tahan says.

Tahan, a member of the National Transitions of Care Coalition convened by the Case Management Society of America, helped come up with a model for communication during transitions of care as patients move through the health care continuum. (See model.)

Successful communication means that an accountable clinician transmits accurate and complete information in an easy-to-understand form in a timely manner to the proper person at the next level of care, and ensures that the person receives the information and understands it, he says.

Key information must include a summary of what happened at the hospital and what needs to happen post-discharge as well as medications, treatment regimens, results of tests, allergies, personal preferences, status of advance directives, and insurance benefits, Tahan adds.

This means that the person who assumes care of the patient after discharge from the hospital has all the information he or she needs to maintain continuity and consistency in care and to make sure that nothing falls through the cracks, he notes.

"The information should be put together in a clear and concise way that is direct and to the point to allow the clinician at the next level of care to understand why it is being shared and what to do with it, especially as the patient's care transitions to those at the next level of care. Such communication enhances continuity of care and prevents unnecessary readmissions to the hospital," he says.

For instance, the post-acute facility, the home health agency, or the family member caring for the patient needs to know about follow-up appointments and if there are tests or procedures that weren't appropriate in the hospital setting that need to be completed after discharge, he adds.

In the hospital setting, the clinician responsible for communicating with the next level of care is likely to be the case manager.

"In fact, the case manager is the best person suited to assume such a role. As they work with the treatment team and manage patient care activities, case managers almost always are involved in transition of care activities. This means they are a strategic player in preventing medical errors and other problems that can occur with the handoffs of care between care settings and when providers are not managed effectively or properly," Tahan explains.

The person receiving the care-related information may be a case manager at another facility, a physician in the community, a home care nurse, or the patient's caregiver in the home setting, he adds.

Case managers must ensure that the information necessary for effective patient care goes to a specific accountable person at the next level of care who can communicate the information to the rest of the care team, Tahan says.

"In the past, the case manager might have faxed whole or parts of the medical record to the skilled nursing facility but didn't necessarily follow up to make sure the right person got the information or that he or she received it in a timely manner and was aware of how to use such information. Today, direct communication between providers of care at transferring and receiving facilities is a necessity to ensure safe and effective transitions and care outcomes," he says.

CMs, social workers liaisons

At North Hills Hospital, the case managers and social workers are responsible for communicating with the liaison at the next level of care and making sure that pertinent pieces of the medical record accompany patients to the next level of care, says Cynthia Lawson, RN-BC, MBA, CPHQ, director of case management at North Hills (TX) Hospital.

If the patient is going to a skilled nursing facility, long-term acute care hospital, or another institution, the staff make sure that the most recent progress notes, the orders, and any reports from a consultant also accompany the patient to the receiving facility.

"The receiving facility should have a complete picture of patients' conditions when they arrived at the hospital as well as what happened immediately prior to them being transferred," Lawson says.

In addition, the primary care nurses communicate with their counterparts at the post-acute facility just as if it were a shift handoff, she says.

"Most of the post-acute providers who work with us have liaisons who come to the facility to assess the patients and collect their own information, but that doesn't eliminate the need for the nurse-to-nurse report," she says.

If patients are going home with home care, the case managers make sure the home care agency has the history and physical and a reconciled medication list, as well as the doctor's orders, she says.

"Many patients are cared for by hospitalists instead of their community-based physician during their hospital stay. This means the community physician often has no idea what happened during the hospital stay or what kind of follow-up care the patient needs," Tahan says.

Hospitals need to develop ways to communicate with primary care physicians after their patients are hospitalized to inform them about what follow-up needs to be done after discharge, he adds.

Make sure that the patient's primary care physician gets a discharge summary quickly so he or she will be prepared when the patient comes in for a follow-up visit, suggests Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital and health care consultant and partner in Case Management Concepts LLC.

"In addition, the primary care physician needs to know what was prescribed (medication, tests, treatments) for the patient in the hospital so he or she won't end up repeating the same or be unaware of certain important nuances in the care of the patient to maintain safety and prevent deterioration of the patient's condition," Tahan says.

Information may be faxed, mailed, or sent electronically to the community physician, but someone on the team must be accountable for seeing that it is communicated to the proper person at the physician practice and that it is clear and understood, he says.

Case managers should communicate with the patient and family and encourage them to actively participate in the decisions about the next level of care, Tahan says.

"Patients need to know where they are going, and when, what is going to happen at the next level of care, and they must be in agreement for the discharge to succeed," he says.

Patients are in the hospital such a short period of time and it's often hard to catch up with the family, Cunningham points out.

"We have to look for windows of opportunity and adjust the way we communicate, such as e-mailing the family members," she says.

Let your patients know what to expect when they get home and what symptoms to watch for that indicate they should call the doctor, says Cunningham.

Make them aware that they need to follow up with their primary care physician within a week or so and, if possible, help them make an appointment before they are discharged.

At North Hills Hospital, if the patient is going home with home health services, the home health liaison visits the patient's room, explains the services, and how things are going to work.

"It's also a benefit to the patients to help them understand what is coming next and minimizes their apprehension about post-acute care," Lawson says.

Educate your physicians on the need for patients who go home without services to have referral for home care so a nurse can reinforce the discharge planning and make sure the patient can manage at home, Cunningham adds.

Medication reconciliation is an important part of ensuring that patients safely transition to another level of care, Tahan adds.

Case managers need to make sure that patients understand how and when to take their medication. They need to be aware of whether they should keep taking the medication they were taking before they were hospitalized or substitute another medication prescribed during their hospital stay, he adds.

(For more information, contact: Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, e-mail:; Cynthia Lawson, RN-BC, MBA, CPHQ, director of case management, North Hills Hospital, e-mail:; Hussein Tahan, DNSc, MS, RN, CNA, executive director, international health services, New York Presbyterian Hospital, e-mail: