Everything You Need to Know About Hospital Discharge

So, you’re ready to leave the hospital. While this may be a time for celebration, it’s also one of the most delicate phases of health. You’re healthy enough to be discharged, but there’s still a chance of something happening that could result in you or your loved one coming right back to the hospital. According to AHRQ, 14% of patients are readmitted to the hospital within 30 days of discharge—and that number rises significantly with age or severity of diagnosis.

How do you keep yourself healthy and out of the hospital? Read on to find out signs to watch for, risks to avoid, and the role a patient advocate can play in ensuring a good outcome for your recovery. 

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Keep your hospital discharge summary

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Discharge summaries play a crucial role in keeping patients safe after leaving a hospital. Your discharge summary is often the only form of communication that accompanies you as a patient to your next care setting. High-quality discharge summaries are generally considered essential for promoting patient safety during transitions between care settings—particularly during that initial post-hospitalization period. Hospitals are, by law, required to provide a summary that includes six high level areas; unfortunately, summaries are all too often not as thorough as they need to be to keep you safe and healthy.

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What is written in a hospital discharge summary?

Your hospital discharge summary should contain the following information:

1. Reason for hospitalization

This will contain a description of the patient's initial presentation upon admission, as well as a description of the initial diagnostic evaluation. What was the patient’s chief complaint? Did the patient’s medical history play a factor in admission? Particularly in this section, it’s important for you to ensure accuracy to the best of your ability. Although unusual, in the care of hospital error, this section can sometimes be changed or massaged to reflect more favorably to the hospital.

2. Significant findings

Similar to the reason for hospitalization, this section will outline the primary diagnoses from the medical staff in more detail.

3. Procedures and Treatment

This will include a description of all events that occurred during the patient’s hospital stay, including consultations, treatments, and/or procedures. Whether the patient is yourself or a loved one, it’s critical to check the accuracy of this section and make sure this description is representative of all procedures and treatments. If you’re struggling to understand the given information, or you suspect that your treatment summary is inaccurate, an independent patient advocate can help you comb this information thoroughly.

4. Patient’s discharge condition

Here, you’ll find documentation that provides context on the patient’s condition at time of discharge. This section, and the next, are essential components that could influence what your insurance will cover after your hospital stay, so you’ll want to pay attention.

5. Patient and family instructions

This is one of the key sections that often is missed or neglected: instructions for care after the hospital stay. This can include a list of discharge medications, activity level guidance for post-discharge, physical or occupational therapy orders, dietary instructions, and guidance on medical follow-up timelines.

An advocate can ensure that your doctor’s instructions are accurately captured, both in-person at the time of discharge as well as independently once you are home. Having an independent voice can help make sure the transition from hospital to home or rehab goes smoothly and can greatly reduce the risk of rehospitalization within the first 90 days.

6. Attending Physician’s Signature

Either electronically or physically, the attending doctor will sign off on this discharge summary.

For more details on the contents of your discharge summary, you can read more at the AHRQ here.

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When you receive your discharge summary

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First, make sure to review your discharge summary as soon as you receive it and ensure that each item has been accurately described. Some areas that are often miscommunicated include diagnoses and tests that occurred before the final diagnosis, various doctors that were seen during your stay (particularly early on in the visit), and any medical episodes that may have occurred, particularly ones that were brief or in the middle of the night that may not have been documented properly.

Make sure that you have received each section of the discharge and that nothing has been left out. You should immediately bring any errors or missing information to the hospital’s attention. And lastly, make sure you hold onto your discharge summary for later use.

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Why keep your discharge summary after you leave?

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Your hospital discharge document will contain critical instructions for care after you’ve left the hospital—but you also need to deliver this document to your primary care doctor. A recent study showed that less than 40% of primary care doctors had access to hospital discharge information, but the information in this document can be immensely helpful to your primary doctor as they continue your care.

If you’re feeling overwhelmed by keeping track of complicated paperwork, a patient advocate from Solace can offer support; find one here.

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Avoiding hospital readmission

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Hospital readmissions are associated with poor clinical outcomes, cost patients and hospitals a significant amount of money, and can frequently be avoided. So, how do you keep yourself or your loved ones healthy and out of the hospital? 

There are three clinically-supported key interventions that have been proven to reduce readmissions. They are:

1. Hospital Discharge Advocacy

A discharge advocate will work directly with you and the hospital staff to make the entire process as smooth as possible. Their role includes:

• Educating the patient about their diagnosis
• Scheduling appointments for clinician follow-up, test result follow-up, and post-discharge testing
• Organizing post-discharge care services
• Confirming the patient’s medication plan
• Reconciling the hospital discharge summary with national guidelines and clinical pathways
• Providing the patient with a written discharge plan, then working with them to make sure they understand each piece 
• Reviewing what to do in case of a problem
• Expediting transmission of the discharge summary to outpatient providers
• Reinforcing the hospital’s discharge instructions and making sure guidance is properly followed. 

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2. Transitional Care Advocacy

A transitional care advocate can help you maintain consistency by coordinating your post-discharge medical team and ensuring accurate information gets to every member of your team when they need it. Their role involves:

• Assessing the hospital’s treatment plan and developing an evidenced-based plan of care
• Regular home visits and ongoing, on-call support for an average of two months post-discharge
• Comprehensive, holistic focus on the patient, from the original reason for hospitalization to other complicating or coexisting events
• Emphasizing early identification and response to health care risks and symptoms, with the goal of avoiding adverse events that might lead to readmission
• Actively engaging patients, their families, and any informal caregivers, including providing education and support
• Communicating to, between, and among the patient, family and informal caregivers, and the patient’s healthcare providers and professionals. 

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3. Care Transitions Programming

The Care Transitions Program is part of the Affordable Care Act and is designed for community-dwelling patients aged 65 and older. It is centered around the use of a Transition Advocate who focuses on improving care transitions by fostering self-management skills in patients.

The Care Transition Program focuses on:

• Medication self-management
• Patient-centered records (PHR)
• Patient/physician follow-up
• Improving patient knowledge of “red flags” or warning symptoms and how to respond

During a home visit, your transition advocate might use role-playing to prepare the patient for follow-up visits with providers and help the patient complete their personal health record. A transition advocate will also coach the patient on how to reconcile or identify discrepancies in medication. They’ll encourage follow-up with healthcare providers, and most importantly, an advocate can serve as a single point of contact for the patient, their family, and their healthcare providers.

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Ultimately, the goal of all of these is to decrease the changes of hospital readmission, reduce errors in medical histories, and improve patient outcomes.

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How can an advocate help?

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When you leave the hospital, you’ve won the battle but you’re not yet through the war. Recovering from any diagnosis can be exhausting and stressful, and taking the necessary steps to follow up with paperwork and people can be cumbersome. You don’t have to go through this alone; an advocate can take this burden from you and help guide you to your best health outcomes. Reach out to an advocate on Solace today.

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