Neil Gulsvig

It is no secret that at the time of discharge, patients are much more likely to succeed in self-managing their own care if they feel prepared and confident. But how do we know when a patient is ready? What factors must be considered when preparing a patient to successfully self-manage and what questions should you be asking?

As we continue our article series“The 7 Key Drivers of Successful Patient Transitions,” we move on to Driver #5: Patient readiness to self-manage. Medicare has developed a checklist for patients and families who are preparing for discharge from a healthcare setting. It prompts patients to talk to staff and then write down information about their conditions, care instructions, medications, appointments and contact information for support and services. 

  1. While this is one approach, it is critical that providers take a patient-centered focus to discharge and have measures in place to determine a patient’s readiness to self-manage.
    In a study investigating the association of nurse and patient assessments of discharge readiness with post-discharge rehospitalizations and ED visits, results noted that nurses tended to rate patients’ readiness higher than the patients themselves. 
  2. Assessment tools have been developed to help healthcare professionals gauge whether patients are ready to leave the hospital to manage their own care.
  3. Verifying that patients are really ready for transition – that they have the best chances to succeed in managing their own health conditions after they leave – is a critical step in comprehensive transition planning.

What can a provider do to measure patient readiness to self-manage? One method is to schedule an appointment with each patient prior to discharge to discuss key questions and help them share their feelings about their experience. Engaging the patient “in-the-moment” about his or her experience and transition readiness has value in several ways. First, it provides another touch point where we acknowledge each consumer first as a person, then as a patient. We can better understand their feelings, needs and expectations, and facilitate engagement in their own health management. Taking the time to solicit patients’ perceptions prior to transition helps enhance the individual experience for each patient.

For patients who may have had an unpleasant experience during their stay, or feel they are not ready for transition, providers are given an opportunity to make things right through service recovery. Providers can turn negative experiences into positive moments for the patients and feel confident in sending a patient home knowing they feel prepared to be successful.  

Take action

Gathering in-the-moment feedback from patients prior to transition provides valuable evidence on which we can base decisions about care and service delivery, our transition planning processes, and the patient experience. Consider these key questions to get started:

  • Is the patient’s medical status stable enough to move to the next care setting?
  • Is the patient/family knowledgeable about health conditions, treatment plans, medications and what to watch for? 
  • Is the patient/family physically and cognitively capable of carrying out self-management skills?
  • Will the patient be able to access healthcare and community resources if needed? 
  • Does the patient have social support once he or she leaves? 
  • Have all arrangements been made and communicated for services, medications, equipment, home modifications and follow-up appointments?
  • Perhaps most importantly, how confident does the patient feel about moving on and monitoring and managing their own health and care?

Consider these strategies to begin developing your internal process to strengthen patient preparedness to self-manage:

  1. Ensure all staff are educated on the concepts of patient engagement, the patient experience, comprehensive transition planning and their value. Be sure to incorporate into orientation for new employees.
  2. Establish a tool that includes both quantitative and qualitative data collection for asking questions to determine patient preparedness to self-manage. While quantitative data are easier to score, graph and compare, qualitative data drill down into the reasons and examples behind the ratings, and expose themes within the feedback.
  3. Focus queries on the patients’ feelings, perceptions and expectations, and their impressions. Collect data that is actionable. What can you do with the data?

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.


2.     Weiss, Marianne RN, DNSc; Yakusheva, Olga PhD; Bobay, Kathleen RN, PhD.  Nurse and Patient Perceptions of Discharge Readiness in Relation to Postdischarge Utilization .Medical Care: May 2010 – Volume 48 – Issue 5 – pp 482-486 doi: 10.1097/MLR.0b013e3181d5feae Brief Report
3.     Linda B. Piacentine, MS, RN, ACNP and Marianne Weiss, RN, DNSc. Readiness for Hospital Discharge Scale: Psychometric Properties. College of Nursing, Marquette University, Milwaukee, WI, USA Thursday, 20 July 2006  This presentation is part of : Developing Measurement Scales and Inventories
4.     Titler, Marita G. PhD, RN, FAAN; Pettit, Debra Matsen PhD, RN. Discharge readiness assessment.  Journal of Cardiovascular Nursing: July 1995