This tool is intended to be a resource for discharge educators (DEs). After providing an overview of the DE's responsibilities and the After Hospital Care Plan (AHCP), it describes in detail how to deliver each of the components of the Re-Engineered Discharge (RED). After studying the material, DEs should:
- Know the procedures for delivering each component of the RED (except the postdischarge followup phone call), including how to create and teach the AHCP.
- Possess communication and educational competencies required for an effective discharge. For additional techniques on delivering the RED to diverse populations, go to Tool 4, "How To Deliver the Re-Engineered Discharge To Diverse Populations."
The goal of the DE is to educate and advocate for patients in order to best prepare them and their caregivers for discharge and success following discharge from the hospital. DEs are charged with making sure the elements of the RED are followed. The DE collaborates with the patients' multidisciplinary medical teams about what happens during the hospital stay and what needs to be done for a safe transition home.
The DE works with medical teams and other hospital staff (e.g., social worker, case manager, discharge planner) to:
- Review the discharge plan that has been developed by the medical team and identify service gaps.
- Address gaps by arranging for appropriate services (e.g., diabetic education, visiting nurse).
- Identify barriers to the discharge plan and strategies to overcome these barriers (e.g., transportation issues, cost of medicine, anticipated medicine side effects).
- Create the AHCP, an easy-to-understand discharge plan, and teach it in a way that enables patients to understand how to care for themselves once they go home.
In the clinical trial of RED (PDF File, Plugin Software Help), DEs were registered nurses hired specifically to perform DE functions. For the purposes of this tool, we will describe the RED process assuming that the DE will be responsible for all the components of the RED, except for the postdischarge followup phone call. (Go to Tool 5, "How To Conduct a Postdischarge Followup Phone Call.") At your hospital, several staff members may perform RED responsibilities, and the DE may make the followup phone call. For a discussion of these options, go to Step 8: Train Discharge Educators and Followup Callers in Tool 2, "How To Begin the Re-Engineered Discharge Implementation at Your Hospital."
In the clinical trial of the RED, the RED consisted of 11 mutually reinforcing components that are delivered throughout the hospitalization and shortly after discharge. However, only English-speaking patients participated in the trial. To serve diverse populations, including speakers of languages other than English, hospitals will have to provide language assistance. We have therefore added a component on language assistance to the RED. Table 1 summarizes the 12 components of the RED and actions the DE takes to implement these components.
Table 1. RED Components and Discharge Educator Responsibilities
|RED Component||DE Responsibilities|
|1. Ascertain need for and obtain language assistance.||
|2. Make appointments for followup care (e.g., medical appointments and postdischarge tests/labs).||
|3. Plan for the followup of results from tests or labs that are pending at discharge.||
|4. Organize postdischarge outpatient services and medical equipment.||
|5. Identify the correct medicines and a plan for the patient to obtain them.||
|6. Reconcile the discharge plan with national guidelines.||
|7. Teach a written discharge plan the patient can understand.||
|8. Educate the patient about his or her diagnosis and medicines.||
|9. Review with the patient what to do if a problem arises.||
|10. Assess the degree of the patient's understanding of the discharge plan.||
|11. Expedite transmission of the discharge summary to clinicians accepting care of the patient.||
|12. Provide telephone reinforcement of the discharge plan.||
One of the principles of the RED is that all patients should leave the hospital with an easy-to-understand discharge plan. The discharge plan is a planned course of treatment to be given to the patient and used by the patient after leaving the hospital. The discharge plan is distinct from the discharge summary, which is a summary of the medical aspects of the hospital stay, intended for the medical providers.
We call the discharge plan the AHCP, because the patients are often not familiar with the word "discharge." The AHCP is a booklet that presents the information patients need to prepare for the days between discharge and the first visit with the clinician in charge of the patient's outpatient care. While this will frequently be the patient's primary care provider (PCP), sometimes specialists serve this role. In this toolkit we use the term PCP to refer to the clinician who has main responsibility for the patient.
The AHCP is designed to be easily understood, even for patients or caregivers with limited health literacy. The AHCP is finalized, printed, and used as a teaching aid by the DE in teaching patients what they need to know in order to take care of themselves when they go home from the hospital. The DE reviews each part of the AHCP with patients and confirms that they understand what to do when they go home.
The AHCP may be bound with a spiral plastic binder. Patients can be given a magnet with your hospital logo so that they can take it home and hang it on the refrigerator. Then they can open to the color-coded calendar of the next 30 days of events or whatever page is most important to them.
The components of the AHCP are:
- A personalized cover page with the patient's name, date of discharge, name of hospital, and name and phone numbers of the people to contact with questions: PCP, DE, outpatient case manager, etc.
- Updated list of all medicines with appropriate dose and dosing schedule information.
- A list of medicine allergies.
- A list of upcoming appointments with clinicians, including visiting nurses, tests, etc., for the next 30 days. This includes location of appointments and numbers to call if the patient needs to reschedule.
- A 30-day calendar that is color coordinated to the appointments.The calendar also indicates what day to expect a followup phone call, and observed cultural and religious holidays to trigger the DE and the patient to consider upcoming events that may affect the keeping of appointments.
- A diagnosis information page.
- A patient activation page for the patient to record questions, concerns, and symptoms to be discussed at the followup clinician appointment.
- A list of outstanding test results (when applicable).
- A list of durable medical equipment the patient has or needs to obtain or have delivered to his or her home (when applicable). This includes contact information of the company providing equipment, when it will be delivered, and whom to call if the equipment is not delivered or if there are malfunctions.
- The patient's advanced directives for his or her end-of-life care.
- Recommendations for diet modifications (when applicable).
- Recommendations for exercise or physical activity limitations (when applicable).
This tool contains an annotated example of an AHCP.
The RED patient information Workbook guides the DE step by step to ensure the collection of all the information that is needed to produce an AHCP and complete a RED discharge.
The RED Workstation is a software program that allows the DE to enter all the information that has been collected in the Workbook. You can also upload photographs of the patient's DE and PCP (if you have one) to print on the front cover of the AHCP. Using the Workbook, the DE can enter the RED components into the Workstation as the DE gathers information throughout the patient's hospitalization (e.g., appointments, medicines, diagnosis).
Some of the information can be imported into the Workstation directly from the electronic health record (EHR), therefore eliminating some of the manual entry. Once the information is entered, it is designed to automatically print a personalized AHCP. If your hospital is not using the Workstation, the DE may use the Workbook to generate an AHCP using a template.
Word® templates are available for creating the AHCP for English-speaking patients and for Spanish-speaking patients [Plugin Software Help]. Tool 2, "How To Begin the Re-Engineered Discharge Implementation at Your Hospital," reviews the options for generating the AHCP.
If you are unable to generate an AHCP for any period of time, your patients can collect this information themselves using the guide, Taking Care of Myself: A Plan for When I Leave the Hospital. The guide is available online at http://www.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/goinghome/index.html.
The following sections provide step-by-step guidance for the DE describing how to perform the RED. For the remainder of this tool, we address the DE directly. There are also examples and tips on how to retrieve, document, and teach the RED components.
Before the first meeting with your patient, be sure to read the medical record to familiarize yourself with the events leading up to the admission, the treatment delivered in the hospital so far, and the treatment plan. This information is generally in the admission history and physical section of the chart, in the daily progress notes, and in any consultation notes. This information includes:
- Patient's age, birth date, sex, inpatient doctor's name, and admission date.
- Patient's language preferences for oral communication, phone calls, and written materials and need for an interpreter and translated materials.
- Patient's self-described cultural/racial/ethnic background.
- Diagnoses (admitting diagnosis and comorbidities) and functional status.
- Medicine list (including herbal or natural supplements and other traditional medicine).
- Medicine allergies.
- Sensory deficits.
- Any equipment used or needed at home.
- Test results and completed tests with pending results.
- Advanced directives or health proxy.
- Medical team's discharge plan.
Unless your RED Workstation is programmed to enter this information automatically, enter information into the RED Workbook. For example, diagnosis information is recorded in the Workbook, including:
- Admitting diagnosis: (e.g., chest pain).
- Comorbidities: (e.g., high blood pressure, high cholesterol).
- Discharge diagnoses: (e.g., chest pain, hypertension, hypercholesterolemia).
Before meeting with your patient, be sure to contact the in-hospital medical team with whom you will collaborate throughout the patient's hospital stay. Be sure the team knows your role and keep them informed of your work with the patient. Do not hesitate to ask questions. The following is a list of items to cover with the medical team:
- What is the best way to communicate with the medical team (e.g., pager, Email, telephone)?
- When is the best time to check in each day?
- Can you confirm the diagnosis(es)?
- Is the patient aware of his or her diagnosis?
- Is it o.k. to discuss the diagnosis, daily plan, discharge plan, and appointments needed directly with the patient?
- Can you confirm the medicine list for discharge and communicate discrepancies found?
- Are there any difficulties communicating with the patient, family members, or caregivers?
- When is the expected date of discharge?
- Are there any concerns about discharge?
Meet with the patient as soon as possible (within 24 hours) after admission. This will maximize teaching time while the patient is in the hospital. Discussion with family members and other caregivers is also important to a successful transition. More detail about working with families is found in Tool 4, "How To Deliver the RED to Diverse Populations at Your Hospital."
Whenever possible, arrange for caregivers to be present when meeting with the patient or arrange to meet with them separately. It is important to set expectations with patients and their caregivers, to show them that in fact their questions will be answered and that you will take the time to make sure they understand everything they need to know.
If the patient cannot communicate or is not mentally competent to make decisions, you will need to work with the patient's legal proxy. A legal proxy, who may or may not be a caregiver, is the person with legal authority to act on the patient's behalf.
Throughout the hospital stay, you will educate patients using the components of the RED listed above. Studies indicate that patients have difficulty understanding health information that is only communicated verbally. People generally understand and retain less than 50 percent of information discussed, and communication is even more challenging in the hospital setting where patients are sick, stressed, tired, and often medicated. You can increase the chances that patients will understand and retain what you teach them by using the following communication strategies. More information can be found in Tool 4, "How To Deliver the RED to Diverse Populations at Your Hospital."
During the first meeting with the patient, you will introduce the RED and the role of the DE. If language preferences and interpreter needs have been established upon admission, assign the patient to a certified bilingual DE, or arrange for interpreter services for all meetings with the patient. Tips for the first meeting include the following:
- Ask permission to enter the patient's room.
- Introduce yourself by name and identify your role.
- Determine if the patient feels well enough to participate.
- Ask the patient how he or she prefers to be addressed.
- If not already established, ask about language preferences for oral communication, phone communication, and written materials.
- Assess and meet patient's language assistance needs. If the patient is not proficient in English, and you are not certified bilingual in the patient's preferred language for oral communication, obtain interpreter services. Patients can be ashamed that they do not speak English very well and may claim to understand and say they do not need interpreter services even when they do not understand. Other times patients say that a friend or relative can intepret for them. Let the patient know that it is the hospital's policy to always use a qualified medical interpreter. Do not continue until an interpreter arrives or is connected by telephone.
- Assess and meet language assistance needs of the patient's caregivers. Even if the patient is proficient in English, the patient's caregivers may not be. Caregivers' understanding of the discharge plan will be critical to a safe transition home.
More information on language assistance can be found in Tool 4, "How To Deliver the RED to Diverse Populations at Your Hospital."
Some tips for effective communication strategies that you can use when you meet with your patients include the following:
- Be attuned to body language. When possible, it is advisable to sit.
- Offer encouragement: "You did the right thing by coming to the hospital."
- Express empathy: "It sounds like you've been through a lot."
- Build self-confidence: "With practice you will be able to check your sugar levels."
- Speak slowly.
- Use plain, nonmedical language.
- Listen actively; do not interrupt.
- Do not overload the patient with lots of information all at once; do not cover more than three key points at a time.
It is helpful that the patient and involved caregivers understand your role as the DE and how you will help the patient make a safe and smooth transition from hospital to home. Recognizing the benefits of having a DE will help fully engage the patient and the caregiver in the RED process. When describing the RED and the role of the DE, be sure to emphasize the following points:
- A safe and well-planned discharge from the hospital reduces the risk of unnecessarily returning to the hospital.
- Often there is a lot of new information to learn and remember before leaving the hospital and many patients find this to be challenging.
- The DE will help you learn the essential new information you will need to make a safe transition from hospital to home.
- The AHCP and discharge summary will be sent to your primary care provider to help ensure the smooth transfer of care from the hospital doctors to your primary care provider.
- Your DE will teach you the important things you need to know about your illness, your medicines, and your followup appointments and what to do if you run into problems after returning home.
- Your DE will help answer your questions.
Once the patient understands your role as the DE, continue engaging the patient in discussion that will help you to gather and confirm essential details needed to construct the AHCP. The essential information to gather from the patient includes:
- PCP's name and office location.
- Patient's understanding of illness and treatment.
- Medicines taken at home prior to admission.
- Patient contact information and preferences for followup phone call. (Go to the Contact Sheet.)
- Names and contact information for the health proxy, caregivers, and social support persons. (Go to the Contact Sheet.)
- Pharmacy name and location.
- Medicine allergies.
- Advanced directives and health care proxy.
- Durable equipment he or she has/should have at home.
Record this information in the Workbook.
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.
You will also want to verify and supplement information collected from the medical record. For example, be sure to discuss diagnosis and other comorbidities with the patient, as there may be additional information to gather from the patient not yet captured in his or her medical record that will be very helpful in preparing the patient for discharge. Often patients who are readmitted to the hospital within 30 days of discharge are readmitted for a comorbid condition rather than their original principal diagnosis. If, for example, a patient admitted for chest pain also has hypertension, education about the proper monitoring of hypertension may potentially avoid rehospitalization.
The goal of the followup patient sessions is to teach and reinforce important health and treatment plan information. It also is to identify and address discrepancies between the medical team's discharge plan and the patient's understanding of the discharge plan, as well as barriers to patient understanding. Following the initial meeting, you will make a plan with the patient to return to teach elements of the RED and address any new concerns. Encourage patients to identify someone who can support them during their transition to include in the conversations.
You will not always have the opportunity to teach and reinforce ALL identified elements for each patient. This will often be due to short hospital stays. You will need to assess and prioritize what you will cover based on factors such as:
- Patient's needs, requests, and receptiveness.
- Gaps in the discharge plan.
- Patient's involvement in community services.
- New problems/diagnoses versus old.
- Which parts of the education can be done safely after discharge.
The postdischarge telephone call can be used to deal with the elements that were not fully covered by the time of discharge. It is important to assess whether the patient or caregivers will want interpreter services for phone calls. Do not assume that because people can speak in English without an interpreter at the hospital they will be able to comfortably complete the phone call in English. A telephone presents another hurdle, as it removes context, body language, and lip movement.