There is ever-increasing evidence that shows serious deficiencies in patient care quality exists during transitions between care facilities. Many issues can arise in these circumstances that can jeopardize patient's safety and they all seem to share similar problems and solutions. Issues such as medication errors, lack of appropriate follow-up care, insufficient or inaccurate information transfers are easily avoided. If discharge planners do their part to improve on these issues it will lead to transitions into continuing care that are smoother and will result in happier patients and ultimately better care.
"Know your patient"
The most important aspect of patient care is to "know your patient". This goes beyond knowing only their personal information and medical condition(s). Discharge planners should thoroughly immerse themselves in a patient's medical chart. You must know what care your patient needs at all stages of their care and also be able to explain this in understandable terms to both your patient and their family.
Attempt to reduce transitional issues
Transitional issues are problematic and can be easily remedied with simple solutions. Discharge planners should take extra time in planning their patient's next level of care before hospital discharge. Ensuring the correct choice is made can significantly reduce the amount of patients that end up in facilities that are not the right fit. More often than not, the wrong facility may have an abundance of services that they do not need or simply not have the appropriate level of care for the patient. By providing extra information and counselling to the patient and their families discharge planners can alleviate transition anxiety. Discharge planners should be accountable and thoroughly inform themselves about all long-term care options in order to convey accurate information to patients and their families. They need to thoroughly explain these options to seniors and families, including extensive information on localized options. The easiest way to reduce issues when transitioning from hospital to a SNF is for discharge planners from different facilities to co-operate and to develop localized communication policies that include transition communication and both patient and family involvement.
Co-ordinate with all caregivers
Regardless of medical conditions elderly patients often have multiple care providers involved in their care. Open communication between all care providers is essential to formulate and provide the best possible care to the patient. Remember that not everybody in the care circle is a medical professional as caregivers often include the patient's family and friends.
Establish a strong cross-site communication plan
As we have discussed already there are often multiple care providers that are not always located in close proximity. Establishing a strong cross-site communication plan should be a priority when moving a patient across care facilities. Benefits of a strong plan are extensive and include decreased treatment errors, medication mismanagement, and duplicate or lack of tests and procedures.
Make a patient-owned care record
The patient or their family can help reduce communication errors if they know their healthcare history. Generally the only paperwork that contains this information stays with healthcare facilities and can be delayed by administrative procedures. A patient-owned care record can travel with the patient through transition and ensure the receiving facility has up-to-date information. This care record should include:
All care providers contact information
Patient and family contact information
A complete health history
A list of all current medical conditions including the patient's signs and symptoms
A list of all current medications with dosage information
Before discharge the discharge planner should go through the record with both the patient and their family to ensure it is thoroughly understood and any questions should be answered at this time.
Encourage patient accountability
Upon discharge patients may go from centre-managed care to patient-managed care depending on their destination. This means the patient must become accountable in their care. A step towards ensuring their care does not diminish is education by the discharge planner. Teaching or confirming that the patient knows all of their medical conditions, possible signs and symptoms, and warning signs of change is of utmost importance. Medication education is of equal, if not increased importance as patients may start self-administering medication for the first time. Knowledge of what medication they are on, its different names, side effects and adverse reactions should be both taught verbally and written on a patient reminder card.
Communicate essential information to patients and their family
During the discharge meeting there are areas that should be covered to ease transitional issues and patient anxiety. Things such as: what to know and prepare for discharge, what to expect during the discharge and transition processes, and what to expect at the next level of care.
Have thorough background knowledge of all local next stage facilities
Knowing background knowledge of local care facilities will reduce your research time and give your patient confidence in your ability to successfully get them to the next stage of care. Transitions can be very stressful for all involved and being able to discuss options openly without reading information to the patient can reduce transition anxiety. Having this background knowledge will ensure that at this stage the only thing to research should be bed availability.
As an integral part of the patient transition process, discharge planners can attempt to improve today's serious deficiencies in patient care quality related to transitions between care facilities. By implementing these ten points discharge planners will be well on their way to improving care transitions for their patients and families.
About the Author
Amy comes to the OpenPlacement Blog with an extensive medical background, most recently, 16 years of medical experience as a serving member of the Canadian Forces. Before enlisting in the military, Amy worked in both hospital and in-home care services spending countless hours with seniors in both palliative and non-palliative care settings. Upon releasing from the Canadian Forces she continues her passion for the medical field pursuing a career in medical and technical writing. Amy is currently completing an Advanced Diploma in Business Administration-Accounting and a graduate certificate in Technical Writing.