Care Transitions: Taking Care When Discharging Patients
By Judith Graham, Kaiser Health News
The kidney doctor sat next to Judy Garrett’s father, looking into his face, her hand on his arm. There are things I can do for you, she told the 87-year-old man, but if I do them I’m not sure you will like me very much.
The word “death” wasn’t mentioned, but the doctor’s meaning was clear: There was no hope of recovery from kidney failure. Garrett’s father listened quietly. “I want to go home,” he said.
It was a turning point for the man and his family. “This doctor showed us the reality of my father’s condition,” Garrett said, gratefully recalling the physician’s compassion. A month later, her father passed away peacefully at home.
This kind of caring is what older adults want when they become seriously ill and move back and forth between the hospital and other settings, according to the largest study ever of patients’ and caregivers’ experiences with care transitions.
Two other priorities are also crucially important, according to recently published research: Patients and caregivers want to feel prepared to look after themselves or loved ones when they leave the hospital, and they want to know that their needs will be attended to until they stabilize or recover, however long that takes.
What’s striking is how often hospitals fail to fulfill these expectations, even though it’s been known for decades that care transitions are problematic and strategies to reduce preventable hospital readmissions have been widely adopted.
“Despite millions of dollars of investment and thousands of hours of effort, the health care system still feels very hazardous, unsafe and stressful from the perspective of patients and caregivers,” said Dr. Suzanne Mitchell, assistant professor of family medicine at Boston University School of Medicine and lead author of the new report.
She’s part of a team of experts spearheading Project ACHIEVE, a five-year, $15 million study investigating the effectiveness of interventions designed to improve care transitions. The focus is on what Medicare patients and caregivers need and want when a hospital stay ends and they return home.
One part of the project involves asking people who undergo these transitions — mostly older adults — about their experiences: what went well, what didn’t. In addition to the new report, a survey of more than 9,000 patients and 3,000 caregivers is close to completion. Results will be published this fall.
Another part involves looking at what hospitals are doing to try to improve transitions, such as teaching patients and caregivers how to care for wounds or arranging follow-up phone calls with a nurse, among other strategies. A preliminary research report published last year found common problems with transition programs, including haphazard, uncoordinated approaches and a lack of teamwork and leadership.
Several areas deserve special attention, according to people who participated in focus groups and in-depth interviews for Project ACHIEVE:
Getting Actionable Information
Too often, doctors speak to patients and caregivers in “medicalese” and fail to address what patients really want to know — such as “What do I need to do to feel better?” — said Dr. Mark Williams, Project ACHIEVE’s principal investigator and chief transformation and learning officer at the University of Kentucky HealthCare system.
“You really need someone to walk you through what you’re going to need, step by step,” Williams said.
Nothing of the sort occurred when Anita Brazill’s parents, ages 86 and 87, were hospitalized seven times in Scranton, Pa., between Dec. 25, 2016, and Feb. 13, 2017.
First, her mother needed emergency gastrointestinal surgery, then her father became ill with pneumonia. Both went to an understaffed rehabilitation facility after leaving the hospital, and both bounced right back to the hospital — five times altogether — because of complications.
Each time her parents left the hospital, Brazill felt unprepared.
“You’re out on the concrete of the discharge pavilion and they send you off by ambulance or car without a guidebook, without any sense of what to expect or who to call,” she said.
Ideally, when preparing to release a patient, hospital staff should inquire about older patients’ living circumstances, social support and the help they think they’ll need, and discharge plans should be crafted collaboratively with caregivers.
In practice, this doesn’t happen very often.
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