Involve caregivers in discharge planning

Communication is key to a successful discharge

When providers bring the family caregiver into the discharge process early, there is a better chance that the caregiver will be prepared to care for the patient at home, says Carol Levine, director of the Families and Health Care Project for the United Hospital Fund, a non-profit health services research organization based in New York City.

Beginning in 2010, the United Hospital Fund organized a Learning Collaborative with 37 teams from New York City hospital and post-acute providers to improve transition processes by involving family caregivers. The collaborative was based on the Institute for Healthcare Improvement's Model for Improvement.

"We didn't set out to reduce readmissions, but we clearly saw that engaging the patient and family caregiver does make a difference in preventing problems at home," Levine says.

The first step in the process is to develop a systematic way of identifying the caregiver and including it in the chart so whoever is working with the patient knows who the caregiver is, Levine recommends. Keep in mind that caregivers aren't always the "next-of-kin" or the "contact person." Look for the person who helps the patient at home with activities of daily living, meals, and transportation to medical appointments.

"There typically are a number of people who spend time with patients in the hospital. Clinicians can't just assume that the person at the bedside is the family caregiver. Even if it's the spouse or the oldest daughter, that person might not be the person managing at home," she says.

Keep in mind that the caregiver may be the partner or child of a lesbian, gay, bisexual, or transgender patient. "Lesbian, gay, bisexual, and transgender patients and caregivers often fear, with good reason, that they will be treated disrespectfully by the staff. There should be a zero-tolerance policy against discrimination. Hospitals shouldn't make more problems when there is a willing person who wants to help," Levine says.

It's illegal to tell partners of patients that they aren't real family members, and hospitals cannot use the Health Insurance Portability and Accountability Act (HIPAA) as a way to withhold information from them, she says. "In fact, hospitals should not use HIPAA to withhold information from any family caregiver responsible for the patient's care," she says.

Good communication is the key to a successful discharge, Levine says. "When case managers start talking to family caregivers in an attentive way and engage them in the discharge planning process, they build relationships and often gain information they would not have known otherwise. This saves time and helps them create a successful discharge plan," Levine says.

Involve caregivers in discharge planning early on. "A lot of problems are in timing. Case managers may start planning discharge on the day of admission but they aren't telling family members until the day before," she says. Include caregivers in your medication reconciliation efforts rather than relying on the patient to tell you what medications they are taking at home. Keep in mind that people in the hospital don't feel well and may not remember what you are telling them, so include the caregiver in medication management education.

Involve the caregiver in the decisions about discharge. "It makes a huge difference if caregivers understand what home care really provides, and what they will need to do when the patient gets home. If they know what the impact will be on them, they can make a better choice," she says.

Make sure the person caring for the patient understands what his or her role will be when the patient is discharged and that he or she is willing to do what will be required. For instance, if the patient is going to need wound care, educate the caregiver in the process and make sure that he or she is able to handle it. When you do teach-back, make sure you're really finding out if the patient understands.

Slow down and start listening. Instead of looking at your interactions as teaching the family and patient, look at them as a way to learn the best way to teach them. "Not all patients speak English fluently. Some learn visually. When case managers understand where people are in their own understanding of the disease, it makes a huge difference," she says.