Five steps to a better discharge
Research has shown that patients have a few common priorities at discharge, and hospitalists can tweak their practices to make it more likely these desires are fulfilled.
Do you ask patients if they have any questions as you're discharging them?
Don't pat yourself on the back yet. Almost everyone does that and it rarely leads to any gains in patient understanding, according to Mark V. Williams, MD, FACP, who recorded 98 hospital discharge encounters for research and found that all included that question.
“Out of those 98, a grand total of two patients asked questions,” he reported during his talk “Readmissions: Why Haven't We Fixed This Yet?” at Internal Medicine Meeting 2022, held in Chicago April 28 to 30.
That's not because the patients perfectly understood their discharge instructions. “They want to get the heck out of the hospital. … What they're thinking, though, is ‘What did that mean?’” said Dr. Williams, professor and chief of the division of hospital medicine at Washington University School of Medicine in St. Louis.
To learn even more about what patients are thinking at such moments, he and colleagues around the country asked them and their caregivers, conducting 34 focus groups and 80 interviews as part of Project ACHIEVE.
They found that patients had three top priorities at discharge: They wanted to feel cared for and about, they wanted to feel prepared and capable, and they wanted to be clear on who was accountable for their ongoing care.
To achieve those three goals, Dr. Williams recommended five steps that he said have been linked to more successful discharges.
1. Use caring language and gestures and communicate compassionately. “Our research and others' shows that when you establish this, patient outcomes improve,” he said. “Patients want providers to know them. They want to have them sit when they talk, and actually show concern for their well-being—not that they're one of whatever number of patients the provider's seeing that day.” When patients are shown empathy, they are more likely to trust their clinicians and adhere to their care plan, according to Dr. Williams.
2. Anticipate patients' needs to care for themselves at home. “We're the experts in health care, and we ought to be trying to find out what is necessary for the patients to take care of themselves,” said Dr. Williams. “What do the family caregivers need to know if they need to be engaged in this?” After determining those needs, hospital clinicians should also try to make sure they are fulfilled. He offered the example of health systems that provide patients with transportation to their follow-up visits through a ride-share company. Other needed resources that hospitals can help patients access might include medications, devices, or pillboxes.
3. Engage in collaborative discharge planning with patients and family caregivers. Patients feel supported when they are engaged in the plan for discharge and when it is based on their needs and preferences, Dr. Williams said. The inclusion of their outpatient clinicians may facilitate that. “One thing we found that was very effective at one place I previously worked was ensuring the primary care providers got an email, page, etc., that their patient was in the hospital. With that, we'd ask the primary care providers to call into the patient's room,” he said. “I could tell immediately as a hospitalist when I walked into the patient's room that the primary care provider had called because the patient had a big smile and would say, ‘Oh, Dr. Jones just called me about you taking care of me and said he was so pleased that he had Dr. Williams taking care of his patient.’ It really changed the interaction.”
4. Provide actionable information about diagnosis and treatment. Patients brought this up “over and over again” in interviews, Dr. Williams said. “They did not want 40 or 50 pages of a printout of instructions; they wanted to be told what they needed to do when they were leaving the hospital.” If discharge instructions are tailored to patients' understanding and accompanied by clinical skills training, it will make patients feel capable of self-care, he said. Confirming their comprehension with teachback techniques is also helpful. “I found patients love this. They feel like that physician cares about them because they're checking to make sure they understand,” he said.
5. Provide uninterrupted care with minimal handoffs. This is a challenging objective in hospital care, of course, but clinicians should try to know patients' histories and acknowledge them as individuals, Dr. Williams recommended. Greater continuity in care cultivated greater trust, according to his research. “Ensuring there's communication between the hospitalist and the primary care provider at some point during the hospital discharge, it makes a huge difference,” he said.
That may sound like a lot of work, but it pays off, Dr. Williams concluded, with an expanded quote from Francis W. Peabody, MD, on the subject: “The good physician knows his patient through and through, and his knowledge is bought dearly. Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in the personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity … for the secret of the care of the patient is in caring for the patient.”
