Transition from a Hospital to Home with Ease

Upon being discharged from the hospital, many patients believe that the toughest part of their recovery is behind them. However, in reality, it usually means the beginning of a new routine in a person's health care – one that involves more organization, effort, and awareness. A patient's discharge from the hospital is a critical transition point in the "continuum of care" and is often cited as the ultimate reason for hospital readmission.

About 25% of hospitalized patients experience an adverse event when they transfer from hospital to home. Approximately 62% of those events are considered preventable or able to be improved upon by:

Careful discharge planning by the hospital staff.
How well the hospital staff explains the treatment plan to the patient.
How well a patient understands and carries out the treatment plan after leaving the hospital.
Timely follow up by a physician who is well informed about the details of the hospital stay.

Seniors are at a higher risk for hospital readmissions because they typically have more health issues to consider for their discharge, making their treatment plan more complicated. Also, while seniors represent approximately 12% of the total U.S.population, they account for 70% of hospitalized patients (Census Bureau of Statistics), making them the most vulnerable to discharge procedures.

The physician who is responsible for discharging a patient writes a discharge summary. It specifies the course of treatment while in the hospital; the patient's status at the time of discharge; and the recommendations and expectations for treatment after the patient is released, such as follow-up visits with the doctor, medications, allowed activities, rest recommendations, and diet requirements. The likelihood that a patient will experience complications after discharge and will be readmitted to the hospital increases if:

The discharge care providers (doctors, nurses, discharge planners) do not clearly communicate the instructions on the discharge summary. The patient does not understand the instructions. This can occur because of language barriers, use of uncommon medical terms, or if the patient receives too much information to follow. The patient does not follow through on the instructions, either because they don't understand them or they choose not to abide by them. Results from tests taken while in the hospital are not available at the time of discharge, and therefore, are not included on the discharge summary. Furthermore, these test results may not be forwarded to the physician who performs the follow up visit. The physician who performs a follow-up visit with the patient does not have access to or has not reviewed the discharge summary, and therefore, does not have all necessary information. The path your medical records take after your discharge largely depends on the practices of the hospital where you were admitted. The goal is to get your medical records to your primary care physician, but this can be confusing. Generally, the system works like this: If your primary care physician was your attending physician in the hospital, he or she will have your hospital records forwarded to him or her. Otherwise, the attending physician is responsible for directing copies to your primary care physician, but this is addressed on a case-by-case basis. In all cases, your primary care physician can request your hospital records; he or she just needs to know that you have been in the hospital. So, when you are admitted, you need to remember to list your primary care physician.

According to the Society of Hospital Medicine (, "The interval between hospital discharge and the continuity provider's first post-hospital patient visit is being increasingly recognized as a hazardous hiatus. The patient is vulnerable to a variety of factors that may result in morbidity or hospital readmission, including the recurrence of symptoms that prompted the initial hospitalization, adverse drug events from new medications, new drug-drug interactions, or issues of care coordination, such as follow-up visits and tests. Inadequate social support can further exacerbate the medical complexity of care transition from the inpatient to the outpatient setting."

The Centers for Medicare and Medicaid Serves ( requires that all patients are assessed on the basis of cognition, mobility, and family support before being discharged from a hospital. For true success in the "transition of care" from the hospital to home or to a skilled care facility, the big picture for a patient also means taking into account coordinating medications, planning follow up doctor visits and tests, activating supportive community resources, acquiring durable medical goods if needed, and arranging home health care if necessary.

Care transition professionals are available to assist patients and their caregivers with the transfer process and help them succeed in setting up a new health care approach according to the doctor's orders. These professionals include the hospital's discharge planner, social worker, geriatric care manager, transition care companies, and more. Patients may be responsible for the fees associated with the services provided.

"If we can make sure you get your medications and understand your condition and make sure you get to your follow-up appointments, it would make a world of difference and keep you out of the hospital," says Kathleen Mayeda, coordinator of Homecoming Transitional Care Network, a San Francisco organization that receives private and city funding to help seniors and people with disabilities with their post-hospitalization needs.

When a senior enters a skilled nursing or rehab care facility, family members or a designated care transition professional can work with the patient and the facility's care providers to assure a solid and beneficial care plan is put into place.

The patient and the family members actually have a lot of control over how well the transition period from hospital to home or skilled care facility can go, and they can decrease the chance for difficulties after leaving the hospital.

Tips for a more successful transition experience are:

If someone else will be involved with your care after you leave the hospital, he or she should be present at the time of discharge to hear instructions and ask questions.
Ask to work with the hospital's discharge planner. Every hospital has one.
Be certain that you understand all of the instructions given to you. If you are not sure, ask the doctor, discharge planner, or nurse for further explanation.
Pick up all medications prescribed to you and take them according to the prescription.
Learn how to properly change bandages and clean wounds, if necessary.
If you need durable medical equipment or home health care, work with the discharge planner or social worker to make arrangements.
Make sure your primary care physician receives a copy of the discharge summary and all test results from the hospital. Again, the discharge planner can help arrange this.
Be sure you leave the hospital with full written instructions about your condition, medications, dietary restrictions, recommended activity and rest levels, which symptoms you should expect, what to do if you feel worse after you leave, follow up doctor visits and tests, etc.

Now more than ever, hospitals are held accountable for their quality of care because of a provision in the Patient Protection and Affordable Care Act that became law in March 2010. Information about specific hospitals' readmission rates is now more readily available to the public.

In June 2009, The Centers for Medicare & Medicaid Services began publicly reporting 30-day readmission rates for patients who had been hospitalized and discharged with pneumonia, acute myocardial infarction, or heart failure – all of which are more common ailments for hospitalized seniors. Patients discharged with one of these three conditions are monitored for hospital readmissions through a Medicare rating system of "excess" vs. "expected." Under the new health care reform law, hospitals are now required to report patient data to the Secretary of Health and Human Services. The results of the data gathered to date show that about one in five Medicare patients are readmitted within 30 days after being discharged. Beginning fiscal year 2012, hospitals with "excess" readmissions will face financial penalty by CMS who will be allowed to withhold a percentage of all inpatient Medicare payments.

The next time you or a loved one faces a stay at the hospital, make sure that when you exit the hospital, you have all the information you need to succeed in your new care plan. The care plan may be short-term or long-term, but arming yourself with information about your condition, enlisting the right kinds of support, and committing to your own health care plan will help decrease your chances for a hospital readmission and increase your opportunities for better and faster recovery.

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