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Patients, the Forgotten Health Care Team Members Christy Rakoczy

June 10th, 2013

PatientsCareGiversWith hospital readmission rates under close scrutiny, and hospitals receiving great pressure to reduce readmission rates, there is a sense of urgency about determining how to do so. While providing top notch care 100% of the time while a patient is hospitalized is a large part of ensuring patients recover to a state of healthiness, it is also important to examine the post-hospital experience for patients and how to improve processes so that patients are able to recover swiftly without development of further issues or secondary complications.

One way to ensure that a patient is successful in implementing a care plan upon discharge is by understanding and involving the patient. While this seems elementary, it is actually an issue that needs great focus and improvement. Increasingly, it has been found that many patients are not involved in the development of a plan for how to care for oneself and seek further treatment after discharge. As a result, often patients do not understand or are purely unable to implement the instructions provided to them.

First, often patients and their caregivers are not educated on the care being given in the hospital. Including patients and caregivers by sharing end of shift nursing reports can help individuals to be better knowledgeable about the care being provided in the hospital. Additionally care team meetings which include doctors, nurses, therapists, pharmacists and other staff can include the patient and their caregivers so that each step of the process in the hospital is shared in the group and understood. Also, engaging patients and caregivers by including them in decision making can be critical to ensuring patient success in recovery.

Hospitalized patients are often experiencing high levels of stress. Not knowing the staff that enters the room, having uncertain schedules, and sleep deprivation can all contribute to this. Understanding and mitigating those circumstances to the best of the hospital’s ability will help patients to be better prepared to listen to instructions and make decisions. It will also reduce the overall anxiety upon leaving the hospital to return home.

Teaching patients explicitly how to care for themselves is important. Therapists, during inpatient therapy, should show patients exactly how to perform therapy on one’s own. Medication that is being administered in the hospital, that will also be administered at home, should be explicitly explained. Using the Teach-Back method for all of these will help to ensure that patients are able to care for themselves upon discharge.

Finally, education of patients and caregivers, throughout the entire process of hospitalization, not just at discharge, is the best means of ensuring patients are comfortable with their care plans and able to execute the instructions at home. Patients who are knowledgeable about their conditions, warning signs to look for, how to take medication, and how to seek follow up treatment are far better prepared to take care of themselves, or have their caregivers do so, upon leaving.

By actively involving patients in their treatment and care decisions, and understanding their personal circumstances, doctors and other healthcare professionals can better ensure a successful recovery and a reduction of readmissions.


  1. Jay Drayer, June 11, 2013

    Excellent thoughts Christy! It’s impossible to understate the power that patients (and maybe as much so – loved ones and close friends) all represent in enhancing medical outcomes and reducing readmissions.

  2. Yelena Rybkina June 12, 2013

    Great insight! It’s true that often the most important and obvious task of working WITH the person not FOR them is overlooked. This step is CRUCIAL and can not only help to reduce re-admission, but also empower the individual!

  3. Ninette Tan June 12, 2013

    Teach-back is one of the first things we learned in nursing school and in my career. The power of it is surprising and there is usually positive feedback from both the care team and the patient and or family. It opens up more opportunities to educate on topics that may not have come up otherwise. Great article and thank you for posting.

  4. Glenda Hynes June 15, 2013

    Excellent points. The focus on “unnecessary” and often traumatic re-hospitalization especially for elders and/or those with chronic conditions should bring us back to inclusion of the patient & family prior to discharge. Most readmissions result lack of understanding of disease self-management, diagnostic test results and medication confusion. All part of patient teaching.

  5. Dr E June 24, 2013

    Patient & caregiver’s engagement is going to critical as we as a society and health care system continue to look for ways to provide safe, cost effective care. In addition to involving patients and their caregivers during hsopitalization and discharge, post education and counselling is often a critical element in adhering to medications and treatment regimens. Hiring a clinical phamacist to provide medication education and monitoring is cheaper than having a patient get readmitted to the hospital due to drug related problems that often happens. Great post!
    Dr Erowele – Clinical pharmacist & Editor, CareNovate Magazine


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