Arranging for a postdischarge appointment to follow up on ongoing medical issues is one of the most important components of the RED. The postdischarge appointments include not only clinicians (primary care clinician, specialists, etc.), but also appointments for tests that have been scheduled for after discharge, dates that the visiting nurse will visit the home, day and time of medical equipment delivery, date and times to go to the anticoagulation clinic, etc. All this information is entered into the Workbook and will be printed on the AHCP's appointments page and also on the 30-day calendar. The next section discusses important concepts related to making appointments that are convenient for patients.
Determine Best Times for Appointments and Make Appointments
Before making any appointments, it is helpful to determine which days and times are most convenient for the patient and whoever might be assisting with transportation.
Ask the patient about:
- Whether any friends or family members will be involved in the appointment or transportation.
- Days or times when appointments should not be booked, including cultural or religious holidays the patient observes.
- Days and times that are particularly good.
- Any potential problems keeping appointments.
- Transportation options.
- Whether an interpreter will be needed. (For more information, go to Tool 4, "How To Deliver the Re-Engineered Discharge to Diverse Populations.")
You may say something like:
"I will do my best to make your appointments according to the schedule that we discussed. I'll be back to make sure they will work for you and if not, I'll change them. I'll also make sure you know how to get to them."
If the AHCP is printed using the RED Workstation, then the 30-day calendar automatically lists national and religious holidays or observances. Appointments should be made to avoid these conflicts. Also ensure that there are no conflicts among multiple appointments. After making appointments, verify that your patient, and whoever else will attend the appointment, can make them. Reschedule appointments if it turns out there is a conflict or difficulty obtaining transportation. Confirm that the patient knows how to reschedule if a conflict arises.
Use the information gathered above to complete the corresponding Workbook sections, adding information about appointments as they are made. Once an appointment has been made with the patient's PCP, document:
- PCP name.
- Day, date, and time of appointment.
- Name of clinician to see at appointment (if not PCP).
- Phone number.
- Fax number.
Also document whether the patient has a transportation plan to get to the PCP appointment, and if not, what transportation options were discussed.
For appointments with visiting nurses or a physical, occupational, or speech therapist, include the following information to record postdischarge home services:
- Service (e.g., vital signs).
- Company name (e.g., Visiting Nurse Service of N.E.).
- Contact name.
- Address (e.g., patient's home).
- Date scheduled.
Your patient may need to see a specialist or may have outstanding lab or other tests that need to be completed after discharge. Schedule the appointment and teach the patient or a caregiver the importance of keeping the appointment. Document the following information in the Workbook:
- Day, date, and time of appointment.
- Provider name and location.
- Phone and fax numbers.
- Reason for specialist/test/lab (e.g., arthritis, heart condition).
- How the patient will get to the appointment.
What If the Patient Does Not Have a Primary Care Provider?
If the patient does not have a clinician who takes responsibility for the patient's care (i.e., a PCP), check with the medical team or with hospital administration to learn how new PCPs are assigned at your hospital. Typically, PCP assignment does not require a referral. If your hospital does not have associated community health centers (CHCs), you should attempt to develop relationships with the CHCs and established private practices in the area.
|The CHC associated with a hospital with a large uninsured population had a 2-month waiting list for a PCP appointment. The hospital made an agreement with an outside CHC to reserve two appointments per week for postdischarge followup.|
With some insurance programs, however, the patient may have been assigned a PCP without the patient's knowledge, so it is worthwhile to call the insurer to check. Attempt to find a PCP for the patient based on the patient's preferences, where the patient lives, and his or her payment source (i.e., make sure the PCP accepts the patient's form of insurance or will treat uninsured patients). Ask the patient if he or she has any preferences such as gender or language the PCP speaks. Once a PCP is located, make a followup appointment (preferably in the first week and no later than 2 weeks after discharge) to aid in a safe transition to the ambulatory setting.
An important component of the RED is to ensure good followup for tests done in the hospital with results pending at discharge. These pending test results are frequently not followed up, and many of these test results require action.
Find out about pending tests by reviewing the patient's medical chart, checking the hospital laboratory reporting system, and speaking with the medical team. When the information is identified, it can be recorded in the RED Workbook, including the following information:
- Labs/tests pending (e.g., an examination of tissue from your stomach to look for H. pylori, a bacteria that can bother your stomach).
- Date conducted.
- Date results expected.
- Who will follow up on the results and when (e.g., Dr. Avery, appointment on August 8).
At discharge, explain to the patient that some test results are still not ready. Point out where these tests are noted in the AHCP. Explain which test/lab results are still pending, who will review the results, and when and how the patient will receive this information. You can say something like this:
"Remember having [test/lab] done? You will be ready to leave the hospital before the results from [that/those tests/labs] will be back. We will put them on your AHCP to remind you to ask your doctor about the results when you see [him/her] on [date]."
Many patients leaving the hospital require medical equipment and services to care for themselves at home. Coordination of equipment and at-home services is necessary to safely transition the patient home. The absence of these services can lead to a return to the ED or hospital.
Teach the patient and caregivers about any medical equipment that will be needed in the home after discharge. You will obtain this information by reviewing the patient's medical record and speaking with the medical team. For example, some patients will need oxygen delivered to the home. Enter into the Workbook the relevant information about when the equipment is going to be delivered. This will be displayed in the medical equipment section of the AHCP.
Examples of medical equipment are:
- Hospital bed.
- Portable toilet (commode).
- Mask and equipment to help sleep (CPAP).
- Medicine sprayer (nebulizer).
- Tool to measure how deeply you breathe (peak flow meter).
- Tool to measure blood sugar (glucometer).
Enter into the Workbook the relevant information about each piece of equipment needed. This will be displayed in the medical equipment section of the AHCP.
- Whether the medical equipment has been ordered.
- Company name.
- Delivery date (if ordered).
When reviewing the AHCP, you can discuss the importance of each piece of equipment and how to use it. Whenever possible, use actual examples of the equipment, such as a peak flow meter or glucometer, for more effective demonstration of how to use the equipment. Have the patient show you how he or she will use the equipment at home.
Two of the most important components of the RED are to: (1) identify the correct medicines that the patient should take (and not take) after discharge, and (2) arrange for the patient to obtain the medicine.
The purpose of medicine reconciliation in preparation for hospital discharge is to determine that the patient's discharge medicine list and discharge summary medicine list reflect the most recent and accurate updates made to the patient's medicine plan. Although the Joint Commission requires medicine reconciliation, many hospitals find it challenging. If your hospital does not have an established medicine reconciliation process, it can use resources such as the MATCH Reconciliation Toolkit to develop one. In the meantime, you will need to develop a single, accurate medicine list.
Some tips for discharge medicine reconciliation are:
- Obtain the current list of medicines from the outpatient medical record (when available), the inpatient chart, and in some cases, the patient's local pharmacy records, to determine what medicines the patient has been taking. If no list is available, see if a family member can bring all the patient's medicine containers to the hospital.
- Review the list when you first meet the patient to determine what he or she is taking. You might say:
"We want to make sure that when you leave the hospital, you have a list of all the medicines you should be taking. To do this, you and I will go over the list the hospital has. I'd like you to tell me whether you are currently taking these medicines, and if so how much you take."
- After reviewing all the medicines on the list with the patient, you might say:
"Now I'd like you to tell me if there are any other medicines you are taking that aren't on this list. We may talk to your provider, and even talk to your pharmacy, so that we can make sure everyone has the correct list."
- Ask if the patient uses or plans to use any other types of treatments along with the medicines, such as herbs, dietary supplements, or acupuncture. This can identify potential interactions with prescription medicines. If you are not sure about potential interaction risks, you can consult with a complementary and alternative medicine specialist or Web resources, such as the National Center for Complementary and Alternative Medicine at http://nccam.nih.gov, for more information. More information can be found in "How To Deliver the RED to Diverse Populations at Your Hospital."
- Discuss any discrepancies with the medical team and identify what medicines the patients should and should not be taking. Before discharge, resolve all discrepancies discovered in the medicine list.
- If your hospital inpatient unit has access to the outpatient EHR, update it with the current medicine list.
- Once it is finalized, attach the reconciled list of the medicines to the Workbook and enter it into the Workstation. This should be done as soon as possible because waiting until the day of discharge makes this process error prone.
Identify Problems the Patient Might Have Obtaining Medicine
Explore if the patient might have any problems obtaining the medicines. The section of the Workbook that will help you identify this information includes the following:
- Patient plan to pick up medicines upon discharge: (e.g., wife will drive him to the pharmacy).
- Community pharmacy name.
- Phone number, street address, city.
- Whether the patient requested pill box and whether a pill box was given.
Engage in a dialogue with the patient that could include statements such as the following:
- "What pharmacy will you use to fill your prescriptions?"
- "How will you get to the pharmacy to pick up your medicine - by car, public transportation, or maybe a friend or family member?"
- "Is there anything that might make it difficult for you to pick up your medicines?"
- "Medicines can be expensive. Have you ever had any trouble paying for your medicines?"
If the patient identifies potential problems picking up medicines, then you can engage in a problem-solving conversation to assist in identifying a plan that will be successful. Sometimes it is necessary to discuss these issues with other family members and to elicit their support. For medicines for chronic conditions, explore mail delivery options. It will be helpful for you to have a resource list of pharmacies that will deliver medicines and medical supplies. If you cannot find a way to obtain prescriptions, collaborate with the case manager or social worker about how to obtain these medicines.
If the patient says he or she might have trouble paying for medicines, explore resources to help patients pay for their medicines. For information about overcoming financial barriers to obtaining medicines, Tool 19 in the Health Literacy Universal Precautions Toolkit (PDF [Plugin Software Help]).
Confirm Medicine Allergies
All medicine allergies are confirmed with the patient, documented in the Workbook, and appear in the AHCP. In order to identify the allergy history accurately, review the patient's medical record and inquire about any additional allergies that have not been documented. For example, you can say:
"Did you ever have a bad reaction after you took a medicine, such as an itchy rash or trouble breathing?"
If a patient is prescribed a medicine appearing on the allergy list, or a medicine in the same class, confirm the medical team's awareness of the allergy. In most cases an alternative medicine should be prescribed. Document allergies in the appropriate section of the Workbook and confirm that the patient knows what he or she is allergic to.
The purpose of the RED and the role of the DE are to teach the discharge plan that has been determined by the medical team. The hospital discharge, however, provides an important opportunity to be sure that the patient is on the optimal treatment plan. Many patients are discharged from U.S. hospitals on treatment regimens that do not follow national recommendations. Therefore, identifying and rectifying these inadequacies is an important component of the RED.
Once the discharge diagnoses are known, the treatment plan should be compared with any relevant national guidelines. Visit AHRQ's Guidelines and Measures microsite.
If there are potential discrepancies, you should check to see if the medical team knows of a clear reason for not following the guideline. For example, according to national guidelines patients with coronary artery disease should be on aspirin unless there is a clear documented contraindication. If such a patient is not on aspirin and there is no clear documentation for a contraindication for aspirin, it is important to contact the medical team to discuss potential modifications to the discharge plan. Either the treatment plan will need to be altered or appropriate documentation will be needed to record the contraindication. Remember, your patient will benefit from these "double checks."
The discussion with the medical team can go something like this:
"When reviewing the AHRQ's Guidelines site, I noticed that most patients with [specific diagnosis] are discharged on [medicine]. Is there a reason we shouldn't add this to the treatment plan?"
Once you gather and enter all the information, first into the Workbook and then into the Workstation or Word® template, you will print a final AHCP to give to your patient. If English is not the patient's preferred language for written materials, use the Workstation's capacity to print the AHCP in other languages. If you are not using the Workstation, or your Workstation cannot support the patient's preferred language, arrange for the AHCP to be translated by a qualified translator. (Go to Tool 4, "How To Deliver the RED to Diverse Populations at Your Hospital.")
Sit with the patient and carefully discuss each page of the AHCP. The following four sections give tips about how to teach the patient about the diagnosis, medicines, and appointments, and how to encourage question asking.
Important: Please note that teaching the AHCP will happen throughout a patient's admission, so much of the teaching on the day of discharge is reviewing information and assessing the patient's understanding.
Teach About the Patient's Diagnosis
When the AHCP is printed, it will contain educational information about the primary diagnosis and other comorbidities. Whenever possible, provide patient education materials in the language the patient prefers for written materials. The DE should ask the medical team if the patient is aware of his or her diagnosis before discussing the diagnosis with the patient. Be careful of certain cultural contexts when educating the patient about diagnosis and treatment. (Go to Tool 4, "How To Deliver the RED to Diverse Populations at Your Hospital.")
Patients may have beliefs about what their problem is, what caused it, and what treatment is needed. Before teaching about the person's diagnosis or comorbidities, ask the patient about his or her health beliefs. The RED studies show that up to half of patients are not following their discharge plan 2 to 3 days after discharge. Up to one-third of these are patients who have decided that they are not going to take the medicines prescribed. Thus, exploring health beliefs can assist in treatment plan adherence.
An open-ended question that allows a more detailed response from the patient might be helpful. For example, you might ask:
"What do you think has caused this problem? What do you think will help you get better so that you don't have to come back to the hospital?"
Begin teaching the patient about his or her diagnosis. For example, you might ask:
"The tests have helped the doctors find out what's going on with your body. Would you like me to explain this to you?"
Once you have the patient's permission to deliver information, you can say:
"The reason you have [symptoms/problem] is that [explain diagnosis in plain language]. This is called [medical diagnosis]. May I tell you more details about your medical problem?"
If yes, give the patient the RED illustrated diagnosis information sheet (see the example in "Components of After Hospital Care Plan" at the end of this tool) describing his or her specific diagnosis and use it as a teaching guide. You can help the patient understand why the diagnosis information is important. A few tips include:
- "It can help you to better understand why it is important to take your medicine and keep your appointments."
- "It allows you to talk with your family and friends, who might be able to help you if they have a better idea of your condition."
- "It will help you make better decisions about your care."
If the patient asks for clarification, explain again, using everyday, nonmedical language. You will also need to confirm comprehension (go to the "Teach-Back" section below for tips). Once you are confident that the patient understands his or her diagnosis, you can move on to the next topic.
Teach About the Patient's Medicines
Bring the AHCP, which lists all the medicines, to the patient's room for teaching. You will cover:
- Any changes to medicines (new medicines, change in dose or frequency, etc.).
- The correct dose.
- The time of day to take them.
- What to do if he or she misses a dose.
- The reason he or she is to take them.
- Which medicines to continue taking and which to stop taking.
- How long to take it (even if symptoms go away).
- Potential side effects.
- Not to discontinue without calling the doctor (when appropriate).
- The importance of bringing all medicines to followup appointments.
Go to the "Teach-Back" section below for tips.
Teach About Appointments
After you have made the patient's followup appointments, review the details with the patient, including:
- Appointment date, time, and location.
- How the patient will get there; provide maps and directions if needed.
- The purpose of the appointment.
Remind your patient:
- If for any reason a conflict arises and he or she needs to change an appointment, to call the doctor's office to reschedule.
- That the contact information will be located in the AHCP.
- To bring the AHCP to all appointments.
- That someone from the RED team will call in approximately 48 hours to check in and go over the patient's medicines.
Go to the "Teach-Back" section below for tips.
Patients can feel ashamed to ask questions and often are not even sure what questions they need to ask. Here are some tips for encouraging questions during your sessions with the patient:
- Do not appear to be in a hurry. Patients often do not ask questions because they think the hospital staff are too busy to take the time to answer questions.
- Communicate that you expect questions. For example, you could say, "That was a lot of information. I'm sure you must have questions."
- Listen and do not interrupt. Questions will often emerge if you let patients talk.
- Do not just ask, "Do you have any questions?" Patients often say no even if they do have questions.
- Invite family members and caregivers to ask questions.
Ask Me 3™ was developed to help promote effective communication between patients and providers in an effort to improve patient understanding. This technique can be helpful in teaching the AHCP. The program encourages patients to ask about three things before leaving the medical encounter:
- What is my main problem?
- What do I need to do?
- Why is it important for me to do this?
More information is available at: http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3/ .
The patient should also be encouraged to ask as many questions as he or she needs to in order to completely understand the AHCP. Questions Are the Answer is a campaign created by AHRQ to encourage patients to get more involved in their health care by customizing lists of questions about starting new medicines, surgery, or medical tests. Building a list of personalized questions can empower patients to ask the questions that will elicit the information needed to make informed decisions.
You also need to encourage your patients to ask questions of the providers they see after they leave the hospital. To address this need, the AHCP contains a page that helps guide the patient to prepare for his or her outpatient primary care appointment, and it encourages the patient to write down questions or concerns. The DE can review this page in the AHCP with the patient and describe its purpose and help the patient start to write his or her questions on this page. Family members can contribute to this page as well, as they too may have questions, concerns, or observations of their own.
When asked, "Do you understand," patients will frequently say, "Yes," whether or not they understand. Therefore, an important component of the RED is to confirm that patients actually understand what they are supposed to do to take care of themselves once they go home. If they cannot understand, then someone needs to assist them at home or another plan needs to be implemented. To ascertain when a patient understands what you have taught, use the "teach-back" method, an evidence-based communication strategy described below.
One of the easiest ways to close the communication gap between patients and educators is to use the "teach-back" method. Teach-back is a way to confirm that you have explained to the patient what he or she needs to know in a manner that the patient understands. Patient understanding is confirmed when he or she explains the information back to you in his or her own words. Lack of understanding and errors can then be rectified with further directed teaching and reevaluation of comprehension.
A video demonstration of the teach-back method is available at: http://www.nchealthliteracy.org/teachingaids.html. Some points to keep in mind include:
- This is not a test of the patient's knowledge; it is a test of how well you explained the concepts.
- Be sure to use this technique with all your patients, including those who you think understand as well as those you think are struggling with understanding.
- If your patient cannot remember or accurately repeat what you asked, clarify the information that you presented and allow the patient to teach back again. Do this until the patient is able to correctly describe your directions in his or her own words.
For example, you can use the teach-back method after teaching the patient about:
- The Diagnosis: "I want to make sure I explained things clearly. Please tell me how you would describe your illness."
- The Medicines: "Medicines can be very complicated; I need to make sure I've explained everything. Please show me how you will take your [ask about a specific medicine] when you get home."
- The Appointments: "O.k., tell me where and when your first doctor's appointment will be."
Remind patients that all the information they need to know is in the AHCP. This is not a memory test; they simply need to know where in the AHCP the information is located. After reviewing how to locate the information in the AHCP, ask a series of other questions. After several rounds of teach-back, if the patient still has trouble the medical team should be notified and an alternative plan should be created.
What If My Patient Cannot Understand the Discharge Plan?
Patients who cannot demonstrate understanding of the discharge plan are likely to have difficulty once they go home. If your patient cannot demonstrate an adequate understanding of the discharge plan, then a new plan must be developed.
In some cases this will include being sure that your patient receives care and support from family, friends, or other caregivers once he or she returns home. In this situation, you can ask the patient if there is any person he or she would like to be informed of the discharge plan. When someone is identified, arrangements should be made to orient the caregiver to the AHCP. Have the caregiver present during teaching sessions and confirm the caregiver's understanding with teach-back.
In keeping with Health Insurance Portability and Accountability Act requirements, remember to obtain the patient's written permission to share health information with an identified caregiver and ascertain if the caregiver should receive the followup call in lieu of the patient.
At times, involving the family can lead to potential conflicts. If engaging the family has been difficult, or if the household is a source of conflict or stress, involving a social worker might be particularly important. Social workers can assist with assessment and potential intervention, in an effort to improve communication with and support for the family and to organize a safe discharge.
If a reliable caregiver is not identified, it may be appropriate to arrange for a visiting nurse service or a higher level of community care if necessary.
In the RED studies, we heard over and over from patients that what worried them most about leaving the hospital is that they would not be able to reach their doctor (or any other responsible clinician) if they had a problem. Therefore, an important component of the RED system is that each patient be told before discharge how to contact a medical provider if a problem arises after discharge.
You might try one of the following to initiate this dialogue:
- "Let's talk about what to do if you think you're feeling worse."
- "How about if you think you're having a side effect from a medicine?"
- "What should you do if you're not sure you can get your medicine?"
- "I just want to make sure that you know what you should do if any of this happens."
- "If your caregiver has concerns or questions, let's make sure [he or she] knows how to reach us too if that's ok."
When raising this topic, you might engage in a dialogue with the patient such as:
"I'd like to talk about a few issues that might come up once you get home. I certainly hope that you will do well at home, but just in case there is a problem, here are some phone numbers where you can get help."
Then show the front of the AHCP where the information on how to contact the PCP is listed and reinforce the importance of calling the PCP if problems arise. Also point out that the patient can call the DE with questions.
Review potential problems that may occur. Some areas to review with the patient include:
- New medicine side effects.
- Difficulty getting medicines.
- Worsening symptoms or loss of function.
Also make sure your patient knows what constitutes an emergency (e.g., sudden and severe pain, uncontrolled bleeding) and what should be done in case of an emergency (i.e., call 911; return to the hospital). Coach your patient on what might be normal difficulties associated with his or her condition (e.g., with congestive heart failure, shortness of breath when you exert yourself) versus a more acute situation (e.g., sudden, severe shortness of breath).
Another important component of the RED is to ensure that the clinical information from the hospitalization is transmitted to the clinician responsible for the patient's care after discharge. When the clinical information is not properly transmitted, the "receiving clinician" is unaware of important clinical information and proper ongoing care of active medical issues is in jeopardy. This is a significant patient safety and clinical quality issue.
For these reasons, part of the RED is to transmit the patient's hospital discharge summary and the AHCP to the PCP or the first clinician the patient will see, within 24 hours after discharge. This allows ample time for the clinician to review this information before the patient's followup appointment. Furthermore, if a patient has a problem or question between the time he or she leaves the hospital and the day of the followup appointment, then the PCP will have the information about the hospitalization and can respond to questions or concerns.
This information is typically transmitted by fax or Email, but any manner that is rapid and secure is acceptable. It is important to find out the preferences of the outpatient providers to determine the best mode of transmission.
One barrier to timely transmission of the discharge summary is that the discharge summary at many hospitals is not prepared until much later—in many cases, not until 30 days after discharge. If this is the case at your hospital, then it is very important to work with your hospital administration, nursing and medical leadership, and patient safety officer to implement policies to ensure that discharge summaries are completed in a timely way. In any case, be sure to transmit the AHCP within 24 hours of discharge.
The final component of the RED is to reinforce the AHCP by calling the patient at home in the 2 or 3 days after discharge. It is important to note that this call is not a "social call" but an action-oriented call designed to identify problems or misunderstandings that have developed after discharge and to organize a plan to address these issues. The options for who should carry out this task are described in Tool 2, "How To Begin the Re-Engineered Discharge Implementation at Your Hospital." The content and procedures of the postdischarge telephone call are described in Tool 5, "How To Conduct a Postdischarge Followup Phone Call."
If several staff members fulfill the DE role, one central phone number should be given to patients to contact a DE. The DE can serve as a point of contact for the time between hospital discharge and the patient's first ambulatory care appointment. Your hospital will decide if this line should be covered 5 or 7 days a week. When possible, calls should be returned within 24 hours. Keep a log of when calls were received and when they were returned, as well as the nature of the call and its resolution.
The AHCP provides other opportunities to assist the patient before discharge. These are contained in the Workbook and are printed as part of the AHCP. In addition, frequently educational material is presented by other providers in the hospital that can be reinforced as part of the care transition process. The AHCP is printed with a pocket folder to include other educational materials or documents as needed. These items include:
- Dietary advice: Dietary advice can play an important role in preventing readmission. For example, diet can affect anticoagulation therapy, glucose control, and response to congestive heart failure treatment. Review the patient's chart to determine if the patient has been placed on a special diet. Modified diets are frequently misunderstood by patients and their families. Review materials with patients and families and reinforce instructions using the teach-back method.
- Activity level: Is it important for the patient to start walking everyday? Is there a weight limit for carrying? Is there a driving restriction? Depending on the patient's circumstances, it may be very important to reinforce the importance of activity instructions and limitations and to include reminders about this in the AHCP.
- Self-care: Patients frequently have questions about self-care activities (e.g., wound care) that will be needed. Simple illustrations may be particularly useful.
- Substance abuse and smoking cessation: When addictions are identified, you can address whether the patient is interested in intervention or referral for treatment. These details may be added to the AHCP. The Word® template of the Workbook has places to enter the patient's stage of change (i.e., precontemplation, contemplation, preparation, action, or maintenance and relapse prevention), what the patient reports about his or her substance use, and what current treatment the patient is receiving or whether he or she is interested in treatment information.
- Advanced care planning: Patients who have not assigned a health care proxy or established advanced directives may need additional support to understand why this is useful and how to do this.
Document these additional teaching opportunities in the Workbook and note the date when you complete teaching about them.