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Chapter 2

An Integral Part of the Care Continuum

Preparing patients for discharge starts at their times of admission. Nurses have always embraced a concept called “anticipatory guidance.” It refers to what we can do to guide the patient through what to expect during his entire hospitalization and discharge. This preparation can start the time of admission or even earlier for admissions associated with scheduled procedures.

The key to creating a positive discharge experience lies in managing the patient experience along the entire continuum of care. A well-orchestrated discharge plan is one that begins early and is reinforced throughout the entire hospital stay. One stellar example of this is with total joint surgeries. Evidence-based medicine has created a high degree of predictability that allows a healthcare entity to begin the discharge plan weeks before the admission occurs. Because the pathway is predictable, there have been excellent programs developed to help patients prepare well in advance of their surgeries about what to expect. Patients often attend classes, learn about rehab, and even have a home health visit prior to admission in anticipation of their discharge and recovery.

Something to take forward as you think about PD calls is that the whole experience with discharge starts early on in the overall encounter. If you could do one thing in healthcare that would make such a huge difference in the care and outcomes with your patients, it is this: every patient who comes in contact with you and your providers should leave more informed, more educated, and more confident than when he or she arrived. PD calls fit hand in glove with this goal because follow-up calls continue the relationship with information, education, and reassurance that builds the confidence patients so desperately need.

Some of my recent focus groups with patients affirm that their needs don’t stop just because the discharge has taken place. Their need for follow up is crucial from numerous perspectives. It is clear that an effective discharge should include four essentials:

1.Manage patient expectations

2.Use key words in communication to reinforce crucial information

3.Leave the patient or caregiver crystal clear about next steps

4.Include a follow-up plan

The next section expands on these four ideas.

Discharge Essential #1—Manage patient expectations

Managing expectations is an appropriate goal in numerous encounters along the patient experience pathway. Whether or not we’re talking about discharge, wait times, or what a procedure will entail, it’s important to tell patients what to expect so they can better prepare.

One example of such a conversation would be to say, “Ms. Baird, you need to come back in seven days to get your stitches out. In the meantime, I’m going to show you how to take care of the incision at home. I’m going to talk you through it, and I will also give you written discharge instructions that you can refer back to at home.”

Another example is, “Somebody’s going to be calling you within two days after you get home to check in with you. She’ll review your discharge instructions, medications, and see how you are feeling.”

By having this type of conversation, you’re giving the patient and caregiver a head’s up about what kind of timeframe they’ll be dealing with and the purpose of the expected follow-up call.

Using the example of joint replacement, another thing you might say to manage expectations before admission is, “The average stay in the hospital after a total hip replacement is about three days. I’m going to be explaining to you, step by step, what happens during those three days and what we’ll be doing during that period to help you prepare for your discharge.” This process manages patient and family expectations and helps them prepare for what lies ahead.

The idea here is that, all the way through, you’re managing expectations from the pre-op visit, actual admission, discharge instructions, and to following up at home.

Discharge Essential #2—Use key words

Using key words during discharge discussions is an effective communication technique used to reinforce crucial information. It has become a common practice in many healthcare settings, particularly in patient education. Using key words during your discharge discussions is important in reinforcing important information printed on the discharge documents, but those key words are also terms they’ll see on the survey. Please note: you want to reinforce what’s on the survey, not ask the questions that are on the survey or sway the patient’s answers.

It can be extremely effective to use some of the same words in your follow-up discussion that the patient will see on the survey. You might say, “I’m reviewing these instructions so you know how to care for yourself at home.” Another statement might be, “I’m going to review symptoms or health problems to watch for during your recovery.” By using these phrases, you are helping to raise the patient’s understanding.

You can further reinforce the message by making sure whatever documents you distribute to the patient use the same terminology as the verbal discussion. If you use the term “discharge instructions” in your conversation, make sure the written instructions are clearly labeled as discharge instructions. I’ve seen many beautiful presentations, including folders of information printed on wonderful high-gloss paper with colorful graphics, but nowhere on any of these documents did it say these were discharge instructions. Make sure everything is consistent. It will only help you in the long run.

Next, you want to use the key words to emphasize specific information like “care for yourself at home.” Say, “I’m providing you with information about how to care for yourself at home. I’m going to review symptoms to watch for and talk with you about when to call us. But just a reminder, this is all written out for you in your discharge instructions.” Using those key words and emphasizing them by pointing to the related content in the instructions can be helpful to a patient and family members. This also sets the stage for a successful discharge follow-up call.

Discharge Essential #3—Be clear about next steps

Avoid surprises. Be as clear as possible about what the patient should expect next. By handing patients their discharge instructions in writing and talking through that, you’re going to help avoid surprises. Having discharge instruction conversations in the presence of a significant other or caregiver will also reinforce crucial information.

In my mystery shopping endeavors, I frequently see providers send the family member out to get the car, then proceed to rattle through discharge instructions with just the patient. The feedback we often get from patients about this is that they didn’t remember half of what was said and were more focused on getting out. The feedback we get from family members is usually frustration about not being included in such crucial information.

One family member stated, “I had no idea what was going on. I was told to get the car, so I did. I never would have dreamed they would let my wife go home without me hearing every part of the instructions. After all, I’m the one who is caring for her at home.”

In focus groups, many patients have relayed how frustrating it is to leave the hospital or even the physician’s office wondering, “When are my lab results going to be ready?” or question, “Was I supposed to schedule the appointment or were they?” If a patient is leaving without final results, always tell her how long it will take to get results and who will be contacting whom with the results. If you have instructed the patient to call for results, be sure that you are giving her the correct information and you are prepared to answer questions when she does call. If you expect the patient to make her own follow-up appointments, make sure she knows this as well.

One focus group participant told me how she had left the hospital with instructions to call for her biopsy results. She called and was repeatedly told to call back. First, it was because staff didn’t have the results. After that, it was because they had the results but weren’t allowed to give them to her, and the doctor was out of the office. The patient went from being scared about her results to being furious with the doctor, his staff, and the entire organization.

Patients frequently mention that it is a big dissatisfier when the discharge staff isn’t clear about who is supposed to call whom. Consider their possible concerns: “Am I calling the clinic? Is the clinic calling me? When should I expect that call? Do I need to make my own follow-up appointment or has that been made for me? When is home health coming? When and where do I go for physical therapy? Who is making the referral?”

These are things that come up over and over with patients regarding their PD experience. They may not even realize who to call in order to get questions like these answered. The goal is to make sure that everyone is clear about next steps.

Discharge Essential #4—Include a follow-up plan

We send a lot of messages to patients in marketing, public relations, and advertising about how much we care about them. We talk about our quality and about all those things we think are important and want them to know. Yet, when they walk out the door, and we don’t make a PD call, what’s happening next?

Think about three key objectives, one being patient satisfaction or customer service. You want patients to maintain a “warm and fuzzy” feeling and remember you are concerned, caring, and compassionate. The second objective involves clinical outcomes. You want to make sure that patients understand discharge instructions and what to do next. The third is service recovery, an opportunity to fix problems and make amends where appropriate.

Without a discharge phone call, chances are the next encounter with that patient from your organization is going to be the bill. It’s a very cold communication piece that has nothing to do with physical recovery and certainly won’t ease anyone’s concerns about service issues. What should you do? Manage that expectation and keep the connection with patients by letting them know how soon they will be getting a call from your discharge staff.

Consider the message you send when you discharge patients without follow up. In their minds, they’re still worried, still scared, and still feel like they’ve got questions and need support. So, tell them that you’re going to follow up, and then do it!

The best time to make follow up calls is within the 72 hours after discharge because this is the point where some new or unexpected symptoms arise. It is also the time when you can make sure that patients understood their discharge instructions, and you can reinforce the most important information, including what to do to take care of a wound or scheduling any other kind of follow up that needs to get done.

If you’re on the phone and you hear things that indicate a potential adverse outcome or even a potential readmission, you can address this immediately in the conversation. The call is a continuation of care, a part of the treatment process that improves the opinion of your service as well as clinical outcomes. It is simply the right thing to do.