Approaches to Improving Discharge Planning for Patients with Chronic Diseases
I am working on the project “Optimizing Patient-Initiated Post-Discharge Care in Patients with Congestive Heart Failure” under the mentorship of Dr. Molly Horstman at the Michael E. DeBakey Veterans Affairs Medical Center. Through this project, I have explored patients’ and health providers’ experiences with patient-initiated, post-discharge care following hospital discharge for heart failure. Specifically, the work of my PI has allowed me to analyze interviews conducted with patients with chronic conditions and examine how they utilize health care resources after they have been discharged from the hospital. In the process of analyzing these interviews, I became deeply interested in exploring and analyzing existing approaches for improving discharge planning in order to understand patients’ experiences in the context of current discharge processes. I thus pose the question: What are existing approaches for improving discharge planning for patients with chronic diseases and their relative utility?
I am motivated by this question primarily because the discharge process is one of the most critical aspects of patient care. Many individuals harbor the belief that patients arrive at the hospital, are seen by health professionals, and return home free of ailments. In reality, the healthcare process continues well after patients leave the hospital, as they must translate instructions provided by health professionals into health-promoting behaviors at home (Horstman et al. 2017). This transition from hospital to home is particularly important in the case of chronic diseases such as cardiovascular diseases and diabetes, which persist throughout one’s lifetime and require constant attention in the form of medication adherence, regular checkups, and permanent changes in lifestyle habits (Clarke et al. 2017). Thus, for chronic disease patients, the discharge process must empower patients to engage in health-promoting behaviors and coordinate care among the various actors involved in the patient’s care.
Beyond patients’ health experiences and outcomes, improving the discharge process is also important for the larger healthcare system and national economies. Chronic diseases constitute the principle cause of mortality and morbidity in the U.S. and many countries around the world, generating higher healthcare expenditures and posing a significant economic burden on entire healthcare systems (World Health Organization 2014). Currently, poorly coordinated transitions from hospital to home often result in unplanned emergency department visits and hospital readmissions, costing the U.S. economy approximately $12 billion to $44 billion per year (Clark et al. 2017). Thus, identifying approaches for improving discharge planning is integral to promoting proper utilization of healthcare resources and reducing national healthcare expenditures. In this way, the question I have posed is not only relevant to patients, but also to hospital administrators and other stakeholders focused on maximizing the efficiency and profitability of the healthcare system.
The literature reveals that existing approaches to improving discharge planning focus on three principle actors: healthcare professionals, patients and their caregivers, and the healthcare system. Primarily, education and training for physicians, nurses, and other healthcare staff is critical to establishing a clear delineation of roles and responsibilities and promoting appropriate responses to language, culture, and literacy differences. According to the IDEAL Discharge Planning Implementation Handbook, training for all health professionals should emphasize that discharge planning is not a one-time event but rather a continuous process that occurs throughout the patient’s hospital stay (Agency for Healthcare Research and Quality). Additionally, health professionals should understand the role of caregivers in promoting the patient’s health and should include caregivers in all discharge planning activities.
Health professionals should also receive training on how to respond appropriately to a patient’s culture, as this is critical to providing patient-centered care that reduces the risk of preventable readmissions (Agency for Healthcare Research and Quality). A patient’s cultural background largely shapes their beliefs about the causes, treatment options, and outcomes of their illness (Agency for Healthcare Research and Quality; Saha et al. 2008). If the patient’s health beliefs differ from those of the provider, misunderstandings may arise about the nature of the illness and the appropriate course of action (Agency for Healthcare Research and Quality; Lie et al. 2012). For example, consider an asthmatic patient of Chinese ancestry who is prescribed systemic steroids at discharge (Agency for Healthcare Research and Quality). The patient later returns to the hospital with a severe asthma attack as a result of not adhering to the steroid treatment and instead receiving cupping therapy from a practitioner of traditional Chinese medicine (Agency for Healthcare Research and Quality). In this case, the patient’s cultural beliefs about the appropriate treatment for his illness did not align with the treatment he was prescribed at discharge. The readmission could have been prevented by discussing the patient’s health beliefs more thoroughly prior to discharge and proposing a treatment plan that was acceptable to the patient (Agency for Healthcare Research and Quality; Saha et al. 2008).
In addition to cultural beliefs, health professionals should also receive training on how to respond to language differences (Agency for Healthcare Research and Quality). There are more than 20 million people living in the U.S. with limited English proficiency (LEP), and in clinical encounters LEP significantly impedes patients’ ability to interact with English-speaking healthcare professionals (Agency for Healthcare Research and Quality; Jacobs et al. 2004). Patients with LEP are more likely to experience adverse health events than English-speaking patients, which can often lead to hospital readmissions (Agency for Healthcare Research and Quality). In order to prevent these adverse outcomes, health professionals should receive training on how to connect patients to language interpreters during their hospital stay. Patients who are cared for with the assistance of a professional language interpreter have a shorter length of stay and experience fewer hospital readmissions than LEP patients who do not receive translation services (Agency for Healthcare Research and Quality; Jacobs et al. 2004; Lopez et al 2015). Healthcare professionals must also be trained to arrange appropriate language assistance for the patient after he or she has been discharged, such as when the patient receives a follow-up call or has follow-up appointments (Agency for Healthcare Research and Quality). This facilitates an optimal transition of the patient from hospital to home and promotes the patient’s adherence to positive health behaviors.
Finally, healthcare professionals should also be trained on how to respond to patients’ literacy differences (Agency for Healthcare Research and Quality). Health literary is a patient’s ability to receive and understand basic health information in order to make appropriate health decisions (Agency for Healthcare Research and Quality). Approximately 77 million adults in the U.S. have limited health literacy, and literary barriers are particularly common among minority patients of lower socioeconomic status (Agency for Healthcare Research and Quality; Lie et al. 2012). Just as in the case of limited English proficiency, limited health literacy can significantly hinder a patient’s understanding of important health information and thereby result in hospital readmissions (Agency for Healthcare Research and Quality; Boyle et al. 2017). To respond to patients’ literacy differences, health professionals should verbally communicate the written discharge plan to the patient and caregiver and assess their understanding of the written instructions prior to discharge (Agency for Healthcare Research and Quality). This ensures that the patient and his or her caregiver will be able to refer back to the discharge instructions at any time once they return home. Ultimately, training for healthcare staff provides all members of the healthcare team with a clearer understanding of their roles and responsibilities in the process of providing care that appropriately responds to patients’ culture, language, and literacy level.
While some approaches to improving discharge planning focus on training for healthcare staff, other approaches emphasize educating patients and their caregivers throughout the discharge process by providing clear, culturally-appropriate discharge instructions that facilitate understanding and retention (Horstman 2017). One of the most important aspects of discharge planning is including patients’ caregivers in the discharge process, as caregivers serve as a source of social support for patients and can play a key role in shaping their health behaviors (Rosland and Piette 2010). For example, chronic disease patients are typically advised to make permanent changes to their diet such as reductions in salt or sugar intake. The patient’s caregiver may positively influence the patient’s health behavior by cooking meals that meet these dietary requirements or advising the patient about what foods they should avoid. In this way, the patient’s caregiver can have a positive influence on a variety of health behaviors that are important for chronic disease management such as adherence to medications, attendance at scheduled appointments, maintenance of an appropriate diet, and engagement in physical activity (Rosland and Piette 2010). Thus, it is critical for health professionals to identify the patient’s caregiver at the beginning of the hospital stay and include them in the patient’s care throughout the discharge process (Horstman 2017).
The literature also emphasizes the importance of treating discharge planning not as a single event but rather a continuous process that occurs throughout the patient’s hospital stay (Agency for Healthcare Research and Quality; Marcus 2014). Thus, it is important for healthcare staff to educate patients and their caregivers throughout the hospitalization and not only at the time of discharge (Marcus 2014). For example, at the beginning of the hospital stay, the nurse should ask the patient and caregiver about their goals for the hospital stay and inform them about steps towards discharge. Later in the hospital stay, hospital staff should educate the patient and caregiver about the patient’s condition and explain medications and care practices. Right before discharge, hospital staff may reiterate information that was communicated previously, review follow-up appointments, and provide a checklist that fosters discussion about the patient’s transition home. In this way, educating patients and caregivers throughout the discharge process promotes better understanding and retention of health information, which in turn results in greater adherence to discharge plans and prevents hospital readmissions (Marcus 2014).
A final category of approaches for improving discharge planning focus on health system improvements such as greater coordination of care. Coordinated care is “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services” (McDonald, Sundaram, Bravata 2007; p. 5). Coordinated care activities include identifying needs that may raise the risk of adverse health events, addressing those needs through self-management education, appropriate medical treatment, and integration of care across various settings and providers, and monitoring progress and problems (Chen et al. 2000). Coordinated care differs from the previous strategies in that the healthcare system must be set up in a way that fosters collaboration between patient, family members, primary care provider, specialty providers, and other health professionals throughout the continuum of care in order to optimize patient outcomes (Kim, Marek, Coenen 2016). Thus, coordinated care is not simply the individual actions carried out by patients and healthcare professionals, but rather the cumulative network of health system features and activities that allow for optimal communication and connectivity among the various actors involved in the patient’s care. One example of a coordinated care activity is sending a summary of care to the patient’s primary care provider shortly after discharge. This ensures that the patient’s primary care provider is informed about events that occurred during the patient’s hospitalization and can thereby provide appropriate follow up care. Another example of coordinated care is the development and implementation of information transfer systems such as e-referral systems that allow for a smooth flow of information between the various actors involved in the patient’s care (Metzger and Zywiak 2008). Ultimately, coordinated care improves quality of care and increases the efficiency of the healthcare system by reducing medical errors, identifying problems for early intervention, reducing preventable emergency department visits and hospital readmissions, avoiding duplication of tests and procedures, and supporting patients’ preferences (Clark et al. 2017).
While approaches for improving discharge planning are critical for improving patient health outcomes and improving the efficiency of the healthcare system, these approaches may be constrained by the structural barriers of the American healthcare system. For example, in the case of training healthcare staff to respond to language differences, clinicians may choose not to utilize professional interpreters due to the cost imposed by these services or a perceived increase in the length of the clinical encounter (Jacobs et al. 2004; Lopez et al. 2015). In the same way, approaches that emphasize the education of patients and caregivers throughout the discharge process may be constrained by the demands placed on healthcare staff to see patients as quickly as possible and carry out administrative tasks (Dugdale, Epstein, Pantilat 1999). For example, while a physician may wish to spend as much time as possible with a patient and caregiver to thoroughly explain a certain medication or procedure, he or she may feel pressured to explain the information as quickly and succinctly as possible in order to move on to the next patient. This may hinder the physician’s ability to explain the information at the appropriate literacy level and ensure that the patient and caregiver understand the information as best as possible. Finally, approaches that focus on health system improvements such as greater coordination of care may be constrained by the high cost of implementing certain information transfer systems, which may be viewed in an unfavorable light by healthcare administrators and other stakeholders focused on maximizing the profitability of healthcare services (Information and Communications Systems, 2005).
Ultimately, there are various approaches for improving discharge planning for patients with chronic diseases. Some approaches focus on providing training for healthcare staff, while other approaches focus on providing continuous education for patients and their caregivers. Still, other approaches go beyond micro-level interactions between patients and healthcare professionals and focus on larger-scale processes such as the coordination of care across various sites. While all of these approaches are integral to improving the discharge process, the effectiveness of such approaches may be limited by the structural barriers of the American healthcare system. Thus, it is critical to address these structural impediments while also working to implement interventions that are suited to the existing structure of the healthcare system. To this end, future research should explore the feasibility and utility of existing approaches to discharge planning in the context of the healthcare system in order to optimize the discharge process for patients with chronic diseases.
Boyle, Joseph, et al. “Low Health Literacy Is Associated with Increased Transitional Care Needs in Hospitalized Patients.” Journal of Hospital Medicine, vol. 12, no. 11, 2017, pp. 918– 924., doi:10.12788/jhm.2841.
“Care Transitions from Hospital to Home: IDEAL Discharge Planning Implementation Handbook.” Agency for Healthcare Research and Quality.
Chen, Arnold, et al. Best Practices in Coordinated Care. Mathematica Policy Research, 2000, Best Practices in Coordinated Care.
Clarke, Janice L., et al. “An Innovative Approach to Health Care Delivery for Patients with Chronic Conditions.” Population Health Management, vol. 20, no. 1, 2017, pp. 23–30., doi:10.1089/pop.2016.0076.
Dugdale, David C., et al. “Time and the Patient-Physician Relationship.” Journal of General Internal Medicine, vol. 14, no. S1, 1999, doi:10.1046/j.1525-1497.1999.00263.x.
“Global Status Report on Noncommunicable Diseases 2014.” World Health Organization, World Health Organization, 5 Oct. 2015, www.who.int/nmh/publications/ncd-status- report-2014/en/.
Horstman, Molly J, et al. “Patient Experience with Discharge Instructions in Postdischarge Recovery: a Qualitative Study.” BMJ Open, vol. 7, no. 2, 2017, doi:10.1136/bmjopen- 2016-014842.
“Information and Communications Systems: The Backbone of the Health Care Delivery System.” Building a Better Delivery System: a New Engineering/Health Care Partnership, National Academies Press, 2005.
Jacobs, Elizabeth A., et al. “Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services.” American Journal of Public Health, vol. 94, no. 5, 2004, pp. 866–869., doi:10.2105/ajph.94.5.866.
Kim, Tae Youn, et al. “Identifying Care Coordination Interventions Provided to Community- Dwelling Older Adults Using Electronic Health Records.” CIN: Computers, Informatics, Nursing, vol. 34, no. 7, 2016, pp. 303–311., doi:10.1097/cin.0000000000000232.
Lie, Désirée, et al. “What Do Health Literacy and Cultural Competence Have in Common? Calling for a Collaborative Health Professional Pedagogy.” Journal of Health Communication, vol. 17, no. sup3, 2012, pp. 13–22., doi:10.1080/10810730.2012.712625.
López, Lenny, et al. “Use of Interpreters by Physicians for Hospitalized Limited English Proficient Patients and Its Impact on Patient Outcomes.” Journal of General Internal Medicine, vol. 30, no. 6, 2015, pp. 783–789., doi:10.1007/s11606-015-3213-x.
Marcus, Cara. “Strategies for Improving the Quality of Verbal Patient and Family Education: a Review of the Literature and Creation of the EDUCATE Model.” Health Psychology and Behavioral Medicine, vol. 2, no. 1, 2014, pp. 482–495., doi:10.1080/21642850.2014.900450.
McDonald, K. M., V. Sundaram, and D. M. Bravata. “Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies.” Care Coordination, vol. 7, 2007, Agency for Healthcare Research and Quality (US).
Metzger, Jane, and Walt Zywiak. Bridging the Care Gap: Using Web Technology for Patient Referrals. California HealthCare Foundation, 2008, Bridging the Care Gap: Using Web Technology for Patient Referrals.
Rosland, Ann-Marie, and John D. Piette. “Emerging Models for Mobilizing Family Support for Chronic Disease Management: a Structured Review.” Chronic Illness, vol. 6, no. 1, 2010, pp. 7–21., doi:10.1177/1742395309352254.
Saha, Somnath, et al. “Patient Centeredness, Cultural Competence and Healthcare Quality.” Journal of the National Medical Association, vol. 100, no. 11, 2008, pp. 1275–1285., doi:10.1016/s0027-9684(15)31505-4.