Overcoming Gaps in Discharge Planning

By Eric Carter

When a loved one is getting ready to leave the hospital, the discharge planning process should help you and your family understand what to expect when your loved one returns home. You should be informed about your loved one’s health and any specific medical instructions in regard to their care. However, for one reason or another, it’s not uncommon for there to be gaps in the discharge planning process and for families to be unsure of their responsibilities. 

The majority of gaps in discharge planning come down to poor communication and a lack of continuity of care. Learn more about each of these gaps and discover tips to help overcome these gaps. 

Gap 1: Lack of Communication 

There are various ways that poor communication can negatively impact a senior’s hospital discharge. First of all, hospital staff spends all day investigating and talking about medical conditions. To them, medical terminology comes second nature. However, these terms can be unfamiliar and confusing. As the care team discusses discharge, they might feel like they are speaking plainly, while family members are left wondering what is happening. 

Discharge planners may also be discharging multiple patients at a time and may, unfortunately, be in a rush to help get patients out of the hospital. Instead of taking the necessary time to help patients and their families navigate the discharge process, they might just go through the motions to expedite the process. This can result in patients not fully understanding what is going on or what the next steps are.

RELATED CONTENT: How Families Can Help with Hospital Discharge Planning 

There can also be poor communication between healthcare professionals within the hospital. There are often a number of different nurses and doctors that will see any given patient. These professionals rely on the hospital notes to understand what is happening with a patient. Sometimes, to save time, professionals will share information verbally. But this communication can be forgotten easily. 

On the other hand, a patient might actually withhold crucial information from their care team so that they can get out of the hospital sooner. For example, they might have developed a new symptom in the last 24 hours, indicating that they are not actually ready to be discharged. A lack of communication with the care team can impact a senior’s health long-term. 

Tips to Improve Communication

  • Ask questions to make sure you understand the discharge process, additional procedures, and treatment plan. 
  • Get language assistance if English is not your first language. 
  • Maintain honest and open communication with your loved one and make sure that their needs are shared with the care team. 
  • Stay as informed as possible about your loved one’s condition as possible so you can answer any questions from the care team. 

Gap 2: Poor Continuity of Care 

In the hospital, a senior may receive medical care from a number of different nurses and doctors. But these healthcare professionals will all have the same access to review your loved one’s medical record for the time they have been in the hospital. They can also order tests and lab work to be performed and get results back fairly quickly within the hospital system.

However, when a senior leaves the hospital, the doctors they see will have to be caught up on the medical history. That’s one reason why the hospital provides a written summary of a patient’s stay and their treatment plan.

The idea is that other medical providers can read the summary and be caught up on a patient’s status. However, in about 30% of cases, families fail to provide that summary to their loved one’s doctors. And, unfortunately, even if a family does provide the record, many doctors don’t have the time to devote to reading these summaries before a patient visit.

A primary care physician or a geriatric specialist may skim through the hospital discharge summary and miss nuggets of information that could make all the difference for your loved one. 

RELATED CONTENT: Best Practices for Identifying High-Risk Discharges 

Another aspect that can impact continuity of care is the treatment plan itself. Doctors and healthcare providers may provide a certain treatment plan and level of care that a patient cannot carry out. This could be due to unrealistic expectations for a family, unaware of the patient’s full medical history, or a lack of overall experience in the healthcare system.

For example, if a senior needs an outpatient procedure but their doctor is backed up for three months. Or if a senior is prescribed a certain medication that could actually cause a flare up of another health condition. 

Tips to Improve Continuity of Care

  • Do not leave the hospital without a written summary of your loved one’s hospital stay and treatment plan. 
  • Make copies of the discharge paperwork and ensure that your loved one’s doctors have a copy. 
  • Attend doctor’s appointments with your loved one and make sure that the doctor is aware of your loved one’s condition and the hospital follow-up plan. 
  • Before you leave the hospital, ask the discharge staff what the most important things are for a primary care doctor to pay attention to in the report. This can help you identify and relay the critical information to another care team. 
  • Try to understand each part of the treatment plan and identify who will be able to execute it. 

Benefits of Effective Discharge Planning 

Good discharge planning is important because it directly impact’s a senior’s health. Ultimately, good discharge planning can improve outcomes for your loved one, ensure proper care after leaving, decrease care costs, and reduce the chance of hospital readmission. 

If you or a loved one needs help during the hospital discharge process, know that we are here to help. Our caregivers can help you navigate the process and carry out the care plan effectively so that a senior can maintain their quality of life. Reach out to a local Caring office to learn more. 

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Tags: Hospital