Drive success with effective transition and discharge planning

Neil Gulsvig
Neil Gulsvig

As greater attention is given to ensuring safe and successful patient discharges, those organizations who want to be on the “A” list as a preferred provider of transitional care services must have a strategy in place to ensure patients can successfully self-manage once discharged. 

Unfortunately, it is not uncommon for patient transition instructions to be poorly written, unclear, hard to understand, and hastily pulled together at the last minute. Lack of clarity has the potential to lead the patient right back into the healthcare system when simple and clear instructions may have prevented that. What steps can a provider take to write more effective discharge plans? What needs to be included in a truly patient-centered plan?

As we continue our blog series, “Seven Key Drivers of Successful Patient Transitionswe reach our sixth driver: Clear post-transition instructions. 

Why are post-transition instructions such a critical component of successful patient transitions? Consider a patient transition that is fragmented and not well planned. The patient could easily lack understanding of his or her diagnoses, medications and how to monitor key conditions. These gaps can leave the individual feeling as though they can't take an active role in their healthcare. We know that active patient engagement is key to successful transitions and therefore, the risk of rehospitalizations increases. Research suggests, and we can agree, that quality discharge planning positively affects the quality of healthcare by:

  • Better patient health outcomes
  • Increased patient and caregiver satisfaction
  • Fewer unplanned hospital readmissions
  • Greater patient engagement
  • Health cost savings

What is effective transition planning?

Let's start by talking about what transition planning is NOT. Transition planning is not a document, or a meeting, or a one-time event. Transition planning is a PROCESS of sequential, systematic and continuous actions with the end goal being that the patient is able to safely and adequately manage their condition and treatment plan in their home environment. Transition planning involves taking action – actions that are driven by the patient– actions like discussion, assessment, patient education, resolution of any expectation gaps and referrals.  Transition planning refers to any activity that takes place to meet a patient's post-discharge needs.

Effective transition planning:

  • Is person-centered. The plan is developed WITH the patient, not FOR the patient.
  • Begins before or at admission, evolves throughout the length of stay, and continues as long as we have a relationship with the patient.
  • Involves accurate assessment of the patient's current health and functional status, compared to what will be needed in the home environment, and compared to patient and family expectations.
  • Addresses any gaps identified in health and functional status and patient/family expectations (expectation gaps)
  • Includes timely, appropriate and ongoing patient and family education
  • Has clear communication processes and tools for staff, patients and families
  • Focuses on timeliness and efficiency; avoids last-minute planning and “information dump”
  • Is collaborative and interdisciplinary; involves patient, family, caregivers, and other healthcare providers
  • Focuses on safety and quality care
  • Is individualized, based on the patient's specific condition, needs and desires

Do you have any other ideas for what effective transition planning should or should not be? Feel free to share them in the comments. 

Next month, we'll complete our 7 Key Drivers series by exploring how we can best support patients after transition.

Neil Gulsvig, CEO of Align, has more than 35 years of experience in the field of senior healthcare and extensive knowledge in human resources, communications and operations. Align is focused on developing integrated solutions that help providers reimagine patient experiences through engagement and successful discharge and transition planning.

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