A smooth transition from the health care facility to the home is critical to improving post-hospitalization patient outcomes. Many studies have examined the transition of patients from the hospital to the home, and have focused on discharge planning or post discharge interventions in an effort to improve patient outcomes and reduce unscheduled readmissions.

Age, gender, and race were not predictive of readmission. Numbers of secondary diagnoses,  length of stay, and severity of illness are most consistently predictive of readmissions.

The identified themes for poor outcomes were cultural and language barriers, patient knowledge of whom to contact, lack of care coordination, lack of primary care physician involvement, inconsistent discharge teaching and medication instructions, lack of patient and caregiver empowerment, and patient quality-of-care perceptions. In addition, multiple transitions and miscommunications at all levels of the health care system, as well as between patient and provider, patient and caregiver, provider and caregiver, and between different providers.

 Many studies have used the transitional care model to evaluate post discharge interventions that included more frequent primary care consultations, psychosocial support, family and caregiver training, and extended home health services with advanced practice nurses.  Transitional care attributes include a comprehensive plan of care; the availability of well-trained health care providers to evaluate the complex care needs of patients with acute and chronic illnesses; the sharing of current information across health settings; and addressing the patient’s goals, preferences, and clinical status. The plan further includes logistical arrangements, patient and family education, and coordination among health care providers.

Studies have repeatedly demonstrated the wide gulf between clinicians’ perceptions of how medical information is and should be communicated, and the perceptions of patients and of their caregivers. The importance of incorporating the family and caregiver into the care plan and ascertaining the ability of caregivers to manage patient care, medication regimens, etc., is well known, but not always put into practice.

The majority of the readmitted patients indicate that they understood the discharge instructions and medication regimens from their prior admission. It is possible that some of the patients believed they understood the discharge instructions and/or medication regimens, while in reality they did not. Others may have been confused, but were unwilling to admit it. A minority of patients in our study had significant difficulties communicating with their doctor or other health care providers, which, in some cases, contributed to their readmission.

There appears to be an underlying assumption in the discharge planning process that the patient’s providers knew what had happened before and during hospitalization, that all the patient’s providers had agreed on a care management plan, and that a provider who knew them would care for them in the transition.  This does not usually occur.

There is shared responsibility for health care coordination during hospitalization. After discharge, there often is no one clearly in charge of the transition whom the patient may contact for guidance or to arrange for home health care services. Patients often were instructed to contact their primary care provider for follow up care or for answers to questions, whether or not the primary care provider had been involved in the hospital care.

Solara Medical Group follows high-risk patients, improving communications—including considerations of language and cultural differences—and better coordination of care and follow up when transitioning patients from the hospital to the home could potentially prevent some readmissions. 

Solara Medical Group