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INTRODUCTION

Hospital discharge is a critically important care transition. Due to the complexity and potential for errors inherent in the discharge process, this care transition continues to be an area of focus for many patient safety organizations, regulatory agencies, and quality improvement initiatives.

The discharge transition represents a vulnerable time for patients for several reasons. There is a shift of responsibility from the inpatient care team to the outpatient or postacute care providers, and with that comes great risk for breakdown in communication. Medications and other treatment plans are often adjusted in the hospital, and patients and caregivers are challenged with new self-care tasks and follow-up responsibilities at hospital discharge. Adverse outcomes are common in the postdischarge period, with studies showing that about one-half of patients experience a medical error and approximately one in five patients suffer an adverse event. These adverse events, which include adverse drug events and increased health care utilization such as unscheduled hospital readmissions and emergency department visits, are often judged to have been preventable. Table 14-1 outlines some of the patient, clinician, and system factors that contribute to unsuccessful discharge transitions.

TABLE 14-1Factors Contributing to Unsuccessful Discharge Transitions

RISK STRATIFICATION

Due to the complexity of care transitions, all patients are potentially at risk for an unsuccessful hospital discharge. However, certain patient populations may be at higher risk than others. Most studies of discharge interventions have targeted geriatric patients or patients with specific disease processes, such as congestive heart failure, as these populations are known to have high rates of hospital readmission, upward of 20% within 30 days. Other patient-specific characteristics, such as low health literacy, low socioeconomic status, and psychiatric comorbidity are also associated with worse outcomes after discharge. While it is important to have standardized care processes in place that facilitate safe transitions for all types of patients, it is advantageous to have strategies for identifying patients who may benefit from more intensive care transitions interventions.

There have been several tools and models developed to identify patients who are at highest risk for readmission. However, these models are not able to fully and reliably predict hospital readmission, and many incorporate administrative data that can be burdensome to collect. Thus, having a process to easily flag patients with certain high-risk disease processes, psychosocial factors, and/or frequent health care utilization, is optimal.

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