I have reviewed some of the issues related to poor discharge planning and how it can impact the outcomes of patients. Now I want to move on and discuss ways to improve discharge safety. Make no mistake, these things are easy to say and really hard to manage in the real world because they take time. Something that is lacking in most healthcare settings.
1. Start discharge planning early, not on the day of discharge (think about this as a T minus strategy. T minus 3 days, 2 days, etc. You get the point)
Discharge planning should begin on admission or within 24 hours for most patients (current length of stay for patients is not very long these days, so discharge planning should start at admission). High-risk (for readmission) patients should be identified early using factors such as prior admissions, polypharmacy, heart failure, COPD, cognitive impairment, limited English proficiency, poor social support, homelessness, or need for post-acute services. All of these increase the risk of readmission and are additive. Early planning gives the team time to coordinate equipment, medications, transportation, home care, and follow-up. This is what is aligned with AHRQ guidance and the broader evidence base on structured discharge planning, but it remains difficult.
2. Standardize the interdisciplinary discharge process
Use a common discharge checklist completed jointly by physicians, nurses, case management/social work, pharmacy, and when appropriate rehabilitation or palliative care. At minimum, the checklist should confirm:
- discharge diagnosis and hospital course in plain language
- medication reconciliation completed
- follow-up appointments made
- pending tests identified with an owner
- red-flag symptoms reviewed
- services/equipment arranged
- patient/caregiver understanding confirmed by teach-back
Standardization reduces variation and makes omissions visible before the patient leaves. Joint Commission and AHRQ materials strongly support standardized communication during transitions.
3. Make medication communication a core safety intervention
Medication-related failure is one of the most preventable causes of post-discharge harm. Build a formal process for:
- getting the best possible medication history at time of admission
- reconciliation at discharge
- explanation of every new, stopped, and changed medication
- indication-based medication list in patient-friendly language
- pharmacist counseling session for high-risk patients
- direct communication of the final medication list to primary care, specialists, skilled nursing facility, and community pharmacy when needed
This is one of the highest-yield interventions because the evidence linking pharmacist-supported transitions with lower readmissions and fewer discrepancies is strong.
4. Use teach-back for every key discharge instruction
Do not assume that giving written instructions equals understanding. Remember, most patients do not have a medical background. What is simple for health care professionals is a foreign language to many patients and their families. Have the nurse, physician, or pharmacist ask the patient to explain back:
- why they were hospitalized
- how to take their medications
- what follow-up is needed
- what symptoms require urgent action
- who to call with questions
Teach-back is evidence-based and improves comprehension and self-management.
5. Ensure the handoff to the next clinician actually happens
A discharge summary sitting in the EHR is not enough. The transition record should be transmitted promptly to the next clinician or facility and include the reason for hospitalization, major findings, procedures, treatments, medication list with indications, pending tests, and needed follow-up. The Joint Commission’s transition-of-care standards emphasize timely transfer of this information.
For high-risk patients, add a direct clinician-to-clinician handoff call.
6. Schedule follow-up before the patient leaves
The hospital should not simply advise the patient to “make an appointment.” Arrange follow-up before discharge whenever possible, especially for high-risk diagnoses and patients with complex medication changes. Evidence from systematic reviews suggests post-discharge follow-up is associated with lower 30-day readmission in important populations.
7. Add early post-discharge outreach
A phone call within 24 to 72 hours can identify medication problems, barriers to getting prescriptions, worsening symptoms, and confusion about appointments. For selected patients, nurse-led transitional care, home visits, virtual follow-up, or transition coaches may add benefit. Reviews of transitional care models show these multicomponent approaches can reduce readmissions and emergency visits.
8. Build accountability for pending tests and unresolved issues
Every pending result should have:
- a documented owner
- a tracking process
- a communication plan to the patient and the next clinician
This is a common latent safety gap and should be audited explicitly. AHRQ includes pending items as an essential part of the written discharge plan.
9. Design for health literacy and equity
Use plain language, interpreter services, translated materials, caregiver inclusion, and screening for transportation, food, housing, and medication affordability barriers. Patients with social complexity often need more coordination, not just better paperwork. Equity-centered discharge pathways are increasingly supported because standard processes do not serve all patients equally well.