The discharge process is a transitional period when the patient's care is shifted from the hospital to the home, which can be a very stressful and unsatisfying time for patients (Dudas, Bookwalter, Kerr, & Pantilat, 2001). Discharge planning is a crucial component in continuity of care from the hospital to the home because it informs the patient of their condition and treatment plan, medication use, and offers time for questions and concerns (Bull & Kane, 1996). Patient's whose needs remain unmet during postdischarge care have been found to have significantly higher rates of negative health outcomes, care complications, and readmission rates (Mamon et al., 1992). To improve this poor quality (Bull & Kane, 1996), generally overlooked, and complex process, hospitals have begun performing discharge phone calls (DPCs) after the patient has been discharged from the hospital (Mukotekwa & Carson, 2007). This article will provide details from past research on the importance of discharge planning, the complexity of the discharge planning process, ways to improve the discharge process, and ways DPCs can improve the discharge process. The qualitative analysis will add to the current literature by giving detailed examples and perceptions from hospital staff on the importance and benefits of DPCs on the overall discharge process to transition the patients to their homes.
Why is Discharge Planning Important?
Effective discharge planning is a vital patient-care function (Reiley et al., 2007) that is essential for the timely discharge of patients, accurate medical information, and communication of discharge instructions to the patient for self-care (Balaban, Weissman, Samuel, & Woolhandler, 2008; Henderson & Zernike, 2001) and other care providers for follow-up and additional services (Bowman, Howden, Allen, Webster, & Thompson, 1994; Kripalani, Jackson, Schnipper, & Coleman, 2007), and to reduce and/or prevent hospital readmissions (Henderson & Zernike, 2001; Naylor et al., 1994; Parkes & Shepperd, 2000; Reiley et al., 2007).
Proper discharge planning, instructions, and patient education can ease the patient's transition of care from the hospital to the home, which can reduce rehospitalizations, improve health outcomes (Bauer, Fitzgerald, Haesler, & Manfrin, 2009), and enhance patient-reported self-care practices (Koelling, Johnson, Cody, & Aaronson, 2005). Previous studies found that approximately 20% of patients discharged from the hospital experienced some type of adverse event (Forster, Murff, Peterson, Gandhi, & Bates, 2003; Walker, Bernstein, & Jones, 2009), and over half of the adverse events were medication-related (Costa, Poe, & Lee, 2011). The DPC can help alleviate some of these medication errors (Bowman et al., 1994) in order to reduce readmission rates (Dudas et al., 2001). Studies of DPCs conducted in the emergency department found that patients who had received a DPC exhibited improved health status that significantly decreased the rate of return to the emergency department (Dudas et al., 2001).
What Makes the Discharge Process Complex?
There are many factors that play a role in making the discharge process complex (Bauer et al., 2009), these include patient issues, communication difficulties, documentation problems, time pressures, and policy issues (McKenna, Keeney, Glenn, & Gordon, 2000; Mukotekwa & Carson, 2007). Patient issues can affect the complexity of the discharge planning process, including age, complexity of the patient condition, cognitive deficits, and medication management (Bauer et al., 2009). Furthermore, patient's failure to understand discharge instructions (Dudas et al., 2001) and schedule or attend follow-up appointments can further complicate the continuity of care the patient receives at home and can result in a readmission (Hall, Levant, & DeFrances, 2012). Studies have found that the severity of a patient's illness, along with longer lengths of hospitalization, may lead to more involved and formal discharge planning (Mamon et al., 1992).
Communication problems associated with information dissemination and documentation can inhibit a patient's ability to obtain and understand discharge instructions for self-care at home (Henderson & Zernike, 2001). An influential factor regarding information dissemination and processing relates to the number and variety of providers, groups, and agencies involved in the discharge process (Mukotekwa & Carson, 2007). At the hospital alone, several healthcare providers could play a role in the discharge planning of one patient, including doctors, nurses, therapists, pharmacists, and others, which could lead to poor communication and deficient documentation (Balaban et al., 2008; Bauer et al., 2009; Bull & Kane, 1996; McKenna et al., 2000; Mukotekwa & Carson, 2007). Similarly, documentation and information transfer issues can cause major problems during the discharge process for both healthcare providers and patients (Balaban et al., 2008; Bull & Kane, 1996; McKenna et al., 2000). Lack of support in the community, such as family support, access to primary care, and shortage of community resources, may also complicate the discharge process (Bauer et al., 2009; Bull & Kane, 1996). Lack of support for discharge planning improvement from staff members can further complicate or stall improvements to the discharge process (McKenna et al., 2000). Finally, shorter hospitalizations, increased patient to nurse ratios, and physicians overestimating patients’ understanding of instructions (Dudas et al., 2001) make discharge planning a rushed and often incomplete process (Balaban et al., 2008). However, with the average length of stay shortened over the years (Hall et al., 2012), there may be less time for physicians and nurses to meet with patients to discuss postdischarge needs (Balaban et al., 2008; Bauer et al., 2009; Dudas et al., 2001; Maramba, Richards, Myers, & Larrabee, 2004).
Purpose and Benefits of DPCs
The purpose of discharge planning is to familiarize the patient with their illness, the names, dosing schedule and possible side effects of their medications (Makaryus & Friedman, 2005), and other information intended to support a smooth transition from the hospital to the home (Family Caregiver Alliance, n.a.).
The DPC offers many benefits to both patients and hospitals. A majority of the previous studies on DPCs find that patients and nurses express positive attitudes toward DPCs (Cabezas et al. 2006; Setia & Meade, 2009; Susarla, Black, & Dodson, 2011). The DPC provides patients with the opportunity to ask questions that arise after discharge (Bostrom, Caldwell, McGuire, & Everson, 1996; Bowman et al., 1994). Previous research found that more than 90% of the patients had questions about postdischarge care at home (Bostrom et al., 1996). The lack of knowledge regarding medication management, pain management, wound care, and others often makes patients and caregivers anxious and stressful (Driscoll, 2000; Young, Siden, & Tredwell, 2007). Many patients are unclear about their postdischarge care, such as use of medications (Dudas et al., 2001), side effect of the medications, need of personal care at home, or needs of social services. Family members often share the responsibility of taking care of the patient. Patients and caretakers are often confused about medication instructions, especially when multiple prescriptions are involved (Costa et al., 2011). In most cases, patient's perceive the DPC to be a good way for the hospital to monitor their recovery progress and allows them the opportunity to ask questions (Al-Dawoud, Thompson, & Al-Khaffaf, 2009; Bowman et al., 1994; Braun, Baidusi, Alroy, & Azzam, 2009). DPCs can be an effective method to improve the follow-up care of elderly patients after they are discharged from the Emergency Room (Jones, Young, LaFleur, & Brown, 1997).
Limited healthcare literature focuses on care transitions from the hospital to the patient's home. Furthermore, there is even less literature from the hospital employee perspective on how DPCs can improve care processes during the transitional period. Previous research has been performed on the benefits of the DPC to the patient, while few studies have focused on the impact to the hospital. This study adds to the current literature by using qualitative methodologies to assess the overall impact of the DPC on the transitional care period as perceived by hospital professionals at three levels of implementation management, including top level executives, middle level managers, and end users or nurses performing the DPCs. The use of qualitative analysis can provide a more in-depth assessment of the DPC and discharge planning process across the transitional period and provide rationales for results that may only be speculated about through total reliance on quantitative data.
Sample and Data Collection
A large, metropolitan hospital implemented Studer Group's Evidence-Based Leadership change initiative in September 2005. The DPC program was initiated at the hospital in 2008. Qualitative interviews were performed at the hospital in September 2012 by two members of the research team. The hospital leaders and researchers were interested in learning more about the impact DPCs have on improving the hospital's discharge process and the overall transition of care from hospital to home. They were also interested in capturing the views of personnel at the different levels of the organization about DPCs and their impact on the discharge process. More specifically, they were interested in the views of the top leaders, middle managers involved in an ongoing assessment of improving the discharge process, and nurses who had been involved in conducting DPCs or communicating results of DPCs to other nurses. The interviewees were selected primarily by a hospital leader and a key manager who were most directly connected to the discharge improvement process.
The hospital leaders who were interviewed were promised anonymity and thus quotations are used without specific attribution to any respondent by name or position. Those who were interviewed were classified into three groups: executive leadership team members (N = 7); management team members (N = 11); and nurses who had previously or are currently performing DPCs (N = 6). No effort was made here to compare or contrast responses of the leaders to open-ended questions as there were no apparent differences in what the three types of respondents said about the Studer Group tools and their impacts on the hospital. In only two interview topics, in which leaders were asked to give numeric responses, were responses of the three classifications of leaders compared. The interviewee responses to the questions related to DPCs were aggregated and coded for themes associated with the impact of DPCs.
Interviewees were asked numerous questions about the DPC program in regard to its major benefits to the hospital and the patients, the impact of the DPC on reducing readmission rates, staff's perception of the impact DPCs had on patient satisfaction, and several patient specific problems that are not the focus of this study. The responses to the questions related to DPCs were coded for themes associated with the various impact, successes, and goals of DPCs.
The conceptual model aims to discover the impact DPCs have on patients during the transitional period of healthcare delivery. The first model (Figure 1) illustrates the traditional hospital discharge process, in which the patient is discharged from the hospital and continues self-care at home. The second model, the conceptual model of this paper (Figure 2), depicts the impact of DPCs on both the patient's home care and the hospital's discharge process. The model states that the DPC enhances the patient's self-care process by improving the discharge instructions related to follow-up appointment reminders, medication management, and answering patient questions. From the hospital perspective, these improved components of the discharge instructions have yielded improved patient quality of care during the discharge planning process. At the same time, the DPC helps to improve the hospital discharge process by using patient feedback to improve discharge planning, instructions, and processes at the hospital. Most of the work on DPCs has focused on their impact on patients. The primary addition of this research is reflected in Figure 2 with the emphasis on the feedback of the information on the patient home care experience, via DPCs, together with the feedback of discharge phone caller assessments to nurses engaged in care and to those leaders, managers, and others who are working to improve the discharge process.
The Impact of the DPC on the Patient's Transitional Period
The DPC affects the discharge process by allowing staff to provide better, more detailed discharge instructions to patients after they have been discharged from the hospital. Some of the positive factors associated with improved discharge instructions include medication management, follow-up appointment reminders, and answering patient questions.
The qualitative interviews uncovered several factors that were positively affected from more detailed discharge instructions. The top three include answering patient questions and basic follow-up, medication management, and reminders and scheduling of follow-up appointments. This section will discuss in more detail the impact DPCs had on each of these three factors (Table 1).
The most frequently reported benefit of the DPC was answering patient questions and general follow-up with the patient. Eleven of the respondents reported that DPCs allow callers to answer the patient's questions and provide education on the patient's treatment(s), medication(s), or other problems or questions that arose after discharge. One employee thought the DPC could improve patient satisfaction by allowing the patient to ask questions: “by calling them the next day, you can catch some of those problems [with medications or questions on home care].” One respondent said that DPCs allow the staff to “provide reeducation to instill confidence and make them [the patient] feel better.” Another interviewee commented that the greatest benefit of the DPC to the patient was “being able to follow up with the patient and if they have any problems or questions about their medications, you can solve it the next day. …sometimes we get phone calls like four days later or a week later and they have questions about their medications or something and it's like, ‘You've been discharged a whole week or two.’ By calling them the next day, you can catch some of those problems.” Another respondent gave a similar response: “I think it gives the patient an opportunity—now that they're not in such a rush to get out the door, ‘cause I don't think they would fill out a survey, if they are having problems, to be able to say that they're having issues.”
One postdischarge patient problem stressed across multiple interviews was medication management. Several respondents stated that numerous patients are discharged and do not know how to take their medications or will not fill the prescription because they do not have enough money: “[We've learned the] percentage of patients that get home and don't know what to do for their medical care or how to take their meds, or what percent couldn't get their medications filled or percent that walked out without a prescription.” Another respondent stated that the DPC allows them to “reinforce the key points of here's the medications that you need to take.” Finally, DPCs allow patients to express their problems or concerns about their medications because they were too proud or embarrassed to express them while hospitalized: “… all of a sudden they're home and they don't have the medications that they need. Finally when the discharge phone call comes, they'll tell you, ‘I can't buy my meds,’ or ‘I can't buy my meds and my food.’ For them, it's not something they want to have to tell people, but at some point it becomes a problem and it's generally soon after the discharge.” In some instances, the patient does not have the proper equipment or supplies to manage their medications. One respondent recalled having a diabetic patient who had been discharged and was having problems managing his or her diabetes. The staff member found out during the DPC that the patient did not have a working glucometer and was blindly taking insulin. This story was a learning experience that led to the staff asking all diabetic patients, “Do you have a functional glucometer at home? How do you check your blood sugars at home?”
A third most frequently mentioned benefit of DPCs was to schedule and remind patients of their follow-up appointments. DPCs allow the staff to remind patients about their follow-up appointments, in regard when they are supposed to follow-up and with whom. One respondent reported that “[patients] don't listen very much,” especially at discharge, so performing DPCs allows the staff to reinforce the discharge instructions, including any follow-up appointment information. One interviewee commented “there're issues that [the patient] didn't receive an appointment for a follow up appointment and do not know how, or would not take the initiative on their own to create that appointment, therefore would not have [followed] up and could potentially create a readmission.”
For the hospital, the DPC allows the patient to provide feedback about what and who could have done better or performed well (Figure 3). One respondent stated of the DPC that “…it's helped us identify ways that we can improve the workflow of the discharge process. The patients can identify areas that cause the discharge process to take too long. We've identified situations where sometimes information wasn't being included on the patient instructions that were sent home. We work to remedy the documentation prior to the patient leaving the hospital so they have the most accurate information when they get home, which is a benefit to the patient but it's also a benefit to the hospital.” Another respondent explained “I think what [DPCs] does is gives us a lot of insight into where we can improve our processes prior to the patient leaving the hospital. Many of the issues that we find that come back to us after the patients are discharged are issues that actually many times should have been known before they left the hospital.” For discharge workflow improvement, DPCs shed a light on the imperfections and areas of discharge planning that need improvement. One interviewee mentioned “one of the areas that we had trouble with initially was our discharge process. That has moved from a very big dissatisfier to fairly highly ranked by the patients. I think [the DPC] had a significant impact in the perception of the discharge process.”
Overall Benefit of DPCs to Both the Patient and Hospital
In addition to the benefits of DPCs for patients, respondents also spoke to the value of DPCs for the hospital itself. DPCs’ contribution to patient satisfaction is of value to the hospital. Also, feedback from patients via DPCs regarding elements of care that were positive or negative can be of value to the caregivers and to the hospital in continually improving care. As mentioned previously, the patient feedback during the DPC can highlight areas of inefficiency during the discharge process. This feedback can be used by the hospital to make improvements to the discharge process.
One of the overall goals of DPCs is to reduce and, if possible, avoid hospital readmissions. Five of the respondents stated one perceived benefit or value of DPCs was to prevent or reduce readmissions (Figure 2). Although readmissions were not studied as an outcome in this particular study, the perceptions of staff included such as a benefit of DPCs. One staff member stated “discharge phone calls are basically designed to touch base with the patient within the 24-hour to 48-hours after they've been discharged from the hospital. The benefit of that is basically finding out if there are any problems on transitions or issues … that can be resolved that would prevent them from being readmitted to the hospital.” Another interviewee elaborated “I think the major issue is catching problems that the patients are having early on, rather than not knowing about them, not being able to resolve them, and the patients end up back in the emergency room, or worse, back in the hospital.”
Hospital employees perceive that DPCs positively impact the patients’ care transition from the hospital to their home. Patients received better discharge instructions pertaining to medication management, follow-up appointments, and are given a chance to ask questions about their care. Each of these benefits helps to improve the quality of care and reduce readmission rates. Hospitals benefit from DPCs by improving patient satisfaction through better quality of care and enhancing the discharge process. For the discharge planning process in particular, DPCs help the hospital improve its workflow, document discharge instructions, communication, and process improvement. The DPC helped improve these discharge planning functions by catching patient problems prior to readmission, reeducating patients, providing better instructions on medication management, and allowing the patient to voice concerns and ask questions. In all, DPCs were perceived by hospital staff to be a successful component of the discharge planning process.
This qualitative analysis assessed the impact of DPCs on patient care during the transitional period from hospital discharge to home care. Through the use of DPCs, staff discovered that there were several problems with the discharge planning process that made the care transition for patients more difficult, such as incomplete discharge instructions, patient misunderstanding of discharge instructions, and medication management issues. All of these problems can result in negative patient outcomes and increased readmission rates.
To improve the complex discharge planning process involved in the transitional period, strategic planning must make the discharge process a core part of the patient's care progression from admission to postdischarge (Mukotekwa & Carson, 2007). Previous research shows that discharge education and improved interdisciplinary communication are key areas to improving patient care after discharge (Bull & Kane, 1996; McKenna et al., 2000; Reiley et al., 2007) During the discharge process, patients have been found to be dissatisfied with the quality and amount of information they receive from physicians (Isaacman, Purvis, Gyuro, Anderson, & Smith, 1992). To improve the quality of information, physicians should simplify their language by limiting the use of medical jargon (Isaacman et al., 1992), instructions should focus on key points, such as major diagnoses, medication management, follow-up appointments, and contact information should be provided in case problems arise after discharge (Kripalani et al., 2007). A standardized set of written materials, in contrast to exclusively verbal discharge instructions, allow patients to refer back to the instructions in case any confusion or misunderstandings arise postdischarge (Isaacman et al., 1992; Kripalani et al., 2007). Similarly, research shows that further involvement of nurses during discharge could be a critical change to improve the discharge planning process for patients, particularly with medication management (Reiley et al., 2007).
There are several limitations in this study. One limitation is the use of only qualitative interviews. This limitation is twofold. First, the qualitative interviews were only of hospital executives, leaders, and nursing staff, which lead the results and conclusions to be from only the hospital perspective. Qualitative interviews of patients were not performed; therefore, we can only speculate that patient satisfaction and health outcomes were improved by the DPC as perceived by the hospital employees. The addition of patient qualitative interviews could be a dynamic part of future studies regarding DPCs and transitional care. Second, we can only speculate based on the qualitative interview responses that DPCs helped to reduce readmission rates. A quantitative or mixed method or only quantitative approach would be necessary to conclude such results.
Further research containing quantitative data analysis is required to more accurately determine the impact of DPCs during the transitional period. Improving the discharge process and enhancing the transitional period for patients can have significant impacts on quality of care, patient satisfaction, and readmission rates. DPCs have been shown to improve this stressful and complex process by affirming, answering, and guiding patient questions, comments, and issues that arise postdischarge.
This study is based upon work supported by the National Science Foundation under grant no. IIP-0832439. Any opinions, findings, and conclusions or recommendations expressed in this study are those of the author(s) and do not necessarily reflect the views of the National Science Foundation.
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Dr. Kristin A. Schuller was a postdoctoral research associate at the Center for Health Organization Transformation at Texas A&M Health Science Center through the completion of this manuscript. She is now an Assistant Professor in the masters of Public Health Department at the University of North Dakota. Her research interests include organizational change to improve overall care delivery, quality, and patient safety.
Szu-Hsuan Lin, is currently a doctoral student at Texas A&M University, and she received her MPH from Texas A&M University in 2009. Lin's research interests include the study of vulnerable populations, providing long-term care for the elderly, and reducing disparities in care associated with patients’ race and ethnicity.
Dr. Larry D. Gamm, Regents Professor and Director of the NSF-funded Center for Health Organization Transformation at the Texas A&M Health Science Center, does research on organizational innovation/change, health information technology, and interorganizational partnerships. He has recently published on organizational innovation, health information exchange, organizational technologies, and multiproject management.
Nicholas Edwardson, MS, is a doctoral student in health services research and the Assistant Director at the NSF-funded Center for Health Organization Transformation (CHOT) at Texas A&M Health Science Center. Nick's principal area of research is the impact of change on an organization's employees, finances, and outcomes.
Keywords:© 2015 National Association for Healthcare Quality
discharge planning; performance improvement/quality improvement; research-qualitative