Healthcare has a lot of transitions. A lot. These can occur as a handoff…when information about what is going on with a patient is passed to another provider. If one doctor goes off shift, they transfer the care of the patient to another doctor. This can also be when a patient is admitted from the emergency department to a physician who will care and treat the patient in the hospital. Inpatient teams may transition a patient when one team goes off after a week and a new team comes on. Sick patients who spend weeks in the hospital, may have multiple transitions from one team to the next. It can be difficult to ensure that the long history of the patient is fully passed from one team to the next. The goal is to have a careful transition of all the critical information that would help the inpatient team care for the patient. I have talked about these types of conversations previously, https://patientsafety.systems/2023/10/24/transitions-of-care-can-result-in-patient-harm-when-they-are-done-poorly/
I have also discussed tools that may help with safer transitions of care if clinicians are willing to use them. https://patientsafety.systems/2023/11/16/handover-tools/
But I want to discuss a different type of transition. This is the transition from an inpatient hospital stay to the discharge to home. If handoffs between doctors can be difficult, then it shouldn’t be hard to imagine that the transition from the hospital to the home can be fraught. It is one of the highest risk transitions in healthcare. When poorly done it can result in complications, readmission and even increased mortality.
In that transition of care, responsibility shifts from the inpatient team to the patient, family, primary care clinician, specialists, home health, pharmacy, or post-acute facility. When that handoff is incomplete or poorly coordinated, patients leave with unanswered questions, unclear follow-up, medication discrepancies, pending tests that are not tracked, and warning signs that no one has clearly explained. The Agency for Healthcare Research and Quality (AHRQ) notes that discharge is a period of particular vulnerability for medical errors and adverse events. Complete and detailed discharge plans make these transitions from inpatient to outpatient safer.
This is not a small problem. Classic work in care transitions found that about half of adults experience a medical error after discharge, and 19% to 23% experience an adverse event, most commonly adverse drug events. Although those figures come from earlier foundational work, they remain influential because more recent AHRQ and Joint Commission resources continue to identify discharge medication management along with interprofessional communication as major safety hazards for patients as they move from one setting to the next.
Risks to patients when discharge planning is poor
The most important risks are clustered in a few areas, most of them make sense:
Medication related. Medication changes are common during hospitalization, but the rationale for each change is often not communicated clearly to the patient, the next clinician, or the priamry care team. The Joint Commission highlights ineffective communication between inpatient and outpatient clinicians as a major contributor to medication safety errors at discharge. Pharmacy-led transition reviews have repeatedly shown reductions in readmissions, with counseling and medication reconciliation being the most common effective components. There are programs that have a pharmacy technician visit homes of patients shortly after discharge, just to review medications and make certain that patients and families are aware of new medications and how to look for complications.
Readmissions and emergency visits. When follow-up is not arranged at the time of discharge, post discharge symptoms and problems may worsen before anyone intervenes, or patients return because they do not understand their treatment plan. A 2022 Cochrane review found that structured, individualized discharge planning may reduce readmissions in older medical patients and can improve that patient’s satisfaction. More recent reviews also show that outpatient follow-up after discharge is associated with lower 30-day readmissions in important populations. This is good for patients and good for the bottom line for healthcare systems.
Failure to act on pending tests or unresolved problems. Patients are sometimes discharged before all diagnostic tests and other information is complete. Without a clear owner for pending results, important abnormalities can be missed. AHRQ specifically recommends that written discharge plans include pending items and what follow-up is required for those tests to be safely managed.
Patient confusion and low self-management readiness. Patients may leave without understanding of all the things that happened in the hospital, what medicines to take, what symptoms require urgent help, or who to call. Patients have no medical training and do not understand medical “speak”. Teach-back interventions improve patient knowledge, self-care, and satisfaction, especially in chronic disease populations such as heart failure.
Equity-related harm. Patients with limited health literacy, multiple chronic conditions, transportation barriers, housing instability, language barriers, or fragmented primary care are at especially high risk after discharge. Equity-focused discharge support models that address clinical and social barriers are increasingly being used because routine discharge processes often fail these patients.
This list could go on…. Some people have limited family support or have limited resources to purchase medications or medical equipment that they might need. All of these things, and more, contribute to the enhanced likelihood that patients may end up back in the hospital after discharge, sicker and more vulnerable than ever.
Improvement opportunities come next time.