Excellent transitional care is associated with reduced rates of readmission to the hospital, cost savings and greater patient satisfaction. Readmissions can be avoided if inpatient and outpatient providers communicate effectively, medications are carefully reconciled at multiple key time points, and patients and families are educated about monitoring and care needs after discharge or transfer. The Joint Commission Guidelines for discharge summaries recommend that the following information be included: diagnoses, abnormal physical findings, important test results, discharge medications including reasons for changes, follow-up appointments, education provided to patient and family, and tasks to be completed (Table 13–1). For older adults, documentation of cognitive and functional status, skin condition including description of any pressure ulcers, nutritional status, goals of care, and surrogate decision makers are also important. Detailed medication reconciliation, with the assistance of a clinical pharmacist for patients with complex regimens, is essential to reducing adverse drug events. For patients with cognitive or functional disabilities or psychosocial challenges, a multidisciplinary team including social workers, nurse discharge planners, physical and occupational therapists is essential. Finally, using clear language and a trained interpreter if needed, discharging teams should counsel patients and families about medication changes, outpatient appointments, self-care and “red flags” signaling a call to the doctor or return to the hospital. For the patient transferring to an intermediate site of care, counseling should include a description of what to expect in the next site of care. If there have been major changes in goals of care and treatment limitations, a Physician Order for Life-Sustaining Treatment (POLST) form increases the likelihood that patients will have orders consistent with their wishes in the next setting. Finally, because written discharge summaries do not capture every detail, direct discussion between transferring and accepting providers can be helpful in complicated situations.
The transition from one setting to another is often a good time to review overall goals of care. This type of discussion could include the patient and family’s understanding of the hospitalization and what they are expecting in the next setting. Eliciting specific hopes of future therapies can help discharging providers set realistic goals with the patient and initiate discussion of alternate plans in case those goals are not met.