July 18, 2024

The Secret to a Successful Transition of Care from Hospital to Home


If there’s one thing that a patient in a hospital and his or her caregiver is looking forward to, it is going back home. No matter how simple or how complicated their health condition may be when the doctor says that it is time for discharge, there cannot possibly be any happier news to be heard that day.

Sure enough, a trip to the hospital or prolonged treatment to the hospital is quite intimidating for both the patient as well as the caregiver. But once a routine is established, things may seem more manageable, especially for prolonged treatments.

Hence, when it is time for the patient to go back home or to any other care facility, oftentimes the established routine gets broken and a lot of things go haywire.

Even though it is happy news for everyone, there are a lot of things that need to be carefully addressed and taken care of to facilitate a successful transition, as the patient still needs just as much or perhaps even more care, during and after a transition.

This is an aspect that a lot of hospitals and care facilities overlook when it comes to discharging patients.

As per a survey conducted in Ontario to study post-hospital transitions, many patients were reported to not have received necessary information from their hospitals after the discharge.

In addition, more than half of Canadian patients surveyed reported that they did not receive any documented care plans or information regarding possible symptoms to watch out for or whom to contact in case of emergencies. They were not offered any arrangements for follow-up consultations or hospital visits either.

These are the kind of issues that make the process of transition much harder for the patients and render their care routine useless. Especially if the patients are suffering from health issues with severe mental implications, a slight fault in the care routine can send them down a spiral of depression or anxiety.

What hospitals need to adopt is a successful care transition policy that ensures continued and uninterrupted care for the patients as well as less hassle for the caregivers. And the secret to a successful transition policy lies in “discharge planning”.

From a simple perspective, discharge planning helps ensure that the patient leaves the hospital facility safely, reaches home smoothly and receives the right care after that. It basically facilitates a hassle-free transition for both the patient and the caregiver.

In the process, the patient and the caregiver will be assigned a responsible discharge planner to take care of the process, and together with the caregiver an appropriate plan will be discussed and implemented.

Dr. Brett Lanister of Halo Health Care says that the role of a discharge planner is most crucial and influential in the entire process of transition from hospital to home. It is up to the planner to clear all doubts that the patient and the family may have and make proper arrangements for follow-up consultations.

The discharge planner may be a nurse or a social worker or an administrator or even a case manager. Sometimes for complicated health conditions, a discharge planning team may also be assigned.

Some good practices for successful discharge planning are:

Prompt communication of vital information –

Any important information relating to the diagnosis, tests conducted, their results, medication information etc. should be communicated with the patient and the caregiver immediately upon discharge ideally, or as soon as possible in case there may be pending results to be received. Vital information includes accurate contact information as well for emergency situations, the discharging physician, for follow-up care as well as for general inquiries.

Educating and instructing the patients and caregivers using appropriate methods –

All instructions related to post-hospital care at home regarding medications, food habits or lifestyle changes required need to be properly conveyed to the patient. It should also be ensured that they have understood and remember all instructions accurately using certain methods like the “teach back method” for example where the patient is asked to repeat their care requirements back to the discharge planner.

Reassessment of medication –

At the time of discharge, there are chances that the medication requirements or dosage of medicines may have changed. The discharge planner needs to ensure that the medication list is double-checked for accuracy and also look for any contraindications.

Arranging for timely post-discharge follow-up visits or consultations –

All discharged patients, especially the ones with complicated health conditions have to be followed up promptly to ensure that they are well and cared for. Hence, ideally, a follow-up visit should be arranged by the planner with an appropriate outpatient provider within 7 days of discharge initially. Subsequent follow-ups should also be arranged according to the health condition of the patient.

Following these practices will help ensure a smooth transition of care from hospital to home. All hospitals need to adopt a discharge planning policy for all their discharge cases.

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