The Discharge Process-From a Patient's Perspective

[Discharge management strategies in German general hospitals : A nationwide survey of professionals responsible for clinical risk management]

BACKGROUND

Transitions from inpatient care are associated with risks for the safety of patients. In 2017, the framework agreement on discharge management was legally defined. There is currently a lack of empirical data in Germany on the implementation of measures to ensure safe transitions of patients after inpatient care. The aim of this study is to provide an overview of the discharge management strategies implemented by German general hospitals.

METHODS

Between March and May 2022, specific discharge management strategies as well as structural and organizational characteristics were assessed in a nationwide survey of 401 general hospitals, and descriptive statistics and group comparisons were performed.

RESULTS

Seven of nine strategies surveyed were implemented in > 95% of all hospitals. The evaluation of discharge planning was only implemented in 61% of the hospitals, and systematic documentation, analysis, and evaluation of readmissions in 54%. Hospitals with a higher number of hospital beds reported significantly less often about "early contact with follow-up care providers" and "organization of a seamless transition to follow-up care."

DISCUSSION

A large part of the strategies in discharge management from inpatient treatment is implemented in German general hospitals. However, measures for evaluation and the systematic analysis of discharge processes and readmissions of patients have only been partially implemented. However, these are necessary to systematically evaluate and potentially improve the discharge processes.

Navigating outpatient care of patients with type 2 diabetes after hospital discharge - a qualitative longitudinal study

BACKGROUND

The transition from hospital to outpatient care is a particularly vulnerable period for patients as they move from regular health monitoring to self-management. This study aimed to map and investigate the journey of patients with polymorbidities, including type 2 diabetes (T2D), in the 2 months following hospital discharge and examine patients' encounters with healthcare professionals (HCPs).

METHODS

Patients discharged with T2D and at least two other comorbidities were recruited during hospitalization. This qualitative longitudinal study consisted of four semi-structured interviews per participant conducted from discharge up to 2 months after discharge. The interviews were based on a guide, transcribed verbatim, and thematically analyzed. Patient journeys through the healthcare system were represented using the patient journey mapping methodology.

RESULTS

Seventy-five interviews with 21 participants were conducted from October 2020 to July 2021. The participants had a median of 11 encounters (min-max: 6-28) with HCPs. The patient journey was categorized into six key steps: hospitalization, discharge, dispensing prescribed medications by the community pharmacist, follow-up calls, the first medical appointment, and outpatient care.

CONCLUSIONS

The outpatient journey in the 2 months following discharge is a complex and adaptive process. Despite the active role of numerous HCPs, navigation in outpatient care after discharge relies heavily on the involvement and responsibilities of patients. Preparation for discharge, post-hospitalization follow-up, and the first visit to the pharmacy and general practitioner are key moments for carefully considering patient care. Our findings underline the need for clarified roles and a standardized approach to discharge planning and post-discharge care in partnership with patients, family caregivers, and all stakeholders involved.

Thrown in at the deep end: a qualitative study with physicians on the purpose and challenges of discharge interviews

OBJECTIVES

Against the backdrop of poor discharge communication in hospitals, this study explores the purpose of discharge interviews from the physicians' perspective and the challenges they are confronted with. Discharge interviews are legally required in Germany as part of the discharge management. Led by the ward physician, the discharge interview should summarize relevant information about the hospital stay, medication, lifestyle interventions and follow-up treatment.

METHODS

Semi-structured interviews with n = 12 physicians were conducted at Heidelberg University Hospital between February and April 2020. Qualitative content analysis was carried out using MAXQDA.

RESULTS

Physicians reported gaining information, providing information, and answering open-ended questions as the purpose of the discharge interview. Challenges in conducting discharge interviews were related to finding a common language, patient-related challenges, conditions of everyday ward life, and lack of training. Physicians reported receiving no explicit training on discharge interviews. While professional experience seems to mitigate the lack of training, some physicians expressed a prevailing sense of insecurity.

CONCLUSION

The lack of preparation for discharge interviews in medical school makes it particularly challenging for physicians to translate their theoretical knowledge into patient-centered discharge communication. Medical training on discharge interviews should be expanded in terms of theoretical input on the ideal content, its purpose and potential (e.g. in reducing readmissions), as well as practical exercises.

Engaging Older Adults and Families Using the IDEAL Discharge Protocol: A Quality Improvement Initiative to Improve Outcomes and Reduce Readmissions

Older adults have challenges understanding newly prescribed medications after discharge and must be more adherent with medications and follow up with their primary care provider. A collaborative discharge process is critical to improving patient outcomes and reducing avoidable readmission rates. This quality improvement (QI) initiative engaged 44 patients and families in the IDEAL Discharge Protocol-an evidence-based collaborative care process focused on discussion, education, and post-discharge follow up. Post-discharge follow up resulted in the completion of 52.2% of follow-up calls and 45.5% of follow-up appointments scheduled, and a 4% reduction in readmission rates. Medication adherence was assessed and found to be 93.3%, and 100% of participants received education while engaged in the study. The IDEAL Discharge Protocol aided in improving the discharge process to better equip patients with the tools to transition home successfully after discharge. [Journal of Gerontological Nursing, 49(10), 13-19.].

Patient Perspectives of the Hospital Discharge Process: A Qualitative Study

Care transitions after hospitalization require communication across care teams, patients, and caregivers. As part of a quality improvement initiative, we conducted qualitative interviews with a diverse group of 53 patients who were recently discharged from a hospitalization within a safety net hospital to explore how patient preferences were included in the hospital discharge process and differences in the hospital discharge experience by race/ethnicity. Four themes emerged from participants regarding desired characteristics of interactions with the discharge team: (1) to feel heard, (2) inclusion in decision-making, (3) to be adequately prepared to care for themselves at home through bedside teaching, (4) and to have a clear and updated discharge timeline. Additionally, participants identified patient-level factors the discharge planning team should consider, including the social context, family involvement, health literacy, and linguistic barriers. Lastly, participants identified provider characteristics, such as a caring and empathetic bedside manner, that they found valuable in the discharge process. Our findings highlight the need for shared decision-making in the discharge planning process to improve both patient safety and satisfaction.

Diseño, validación facial y de contenido del instrumento “rol del cuidador familiar en administración de medicamentos”

Objetivo: Diseñar un instrumento para medir la adopción del rol del cuidador familiar en la administración de medicamentos en personas con enfermedad crónica y establecer tanto su validez de contenido como facial. Método: Estudio metodológico que incluyó tres fases: diseño del instrumento, determinación de la validez de contenido con 9 expertos y determinación de la validez facial mediante entrevistas cognitivas a 14 cuidadores y juicios de 30 cuidadores de adultos con enfermedades crónicas. Resultados: Se obtuvo un cuestionario conformado por 32 ítems distribuidos en 3 dimensiones denominadas labores, organización y respuesta ante el rol. El instrumento presentó una adecuada validez de contenido dado que todos los ítems superaron el CVI mínimo de 0,58, mientras que para la escala total fue de 0,97. Por su parte, la validez facial mostró que la claridad fue del 99,6%, la comprensión fue del 98,4% y la precisión fue del 96,9%. Conclusión: El instrumento Adopción del rol en la administración de medicamentos mide de forma lógica el constructo y los ítems que lo conforman representan adecuadamente sus dominios.

Empowering the patient? Medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway

OBJECTIVE

Effective communication and patient empowerment before hospital discharge are important steps to ensure medication safety. Patients discharged from hospitals are often expected to assume self-management, frequently without healthcare personnel (HCP) having ensured patients' knowledge, motivation and/or skills. In this substudy of a larger study, we explore how patients experience medication communication during encounters with HCPs and how they are empowered at hospital discharge.

DESIGN

This is a qualitative case study. Data collection was done through qualitative observations of patient-HCP encounters, semistructured interviews with patients and drug reconciliation. Data were analysed using content analysis.

SETTING

An internal medicines ward at a university hospital in Norway.

PARTICIPANTS

Nine patients aged 49-90 years were included close to the day of discharge.

RESULTS

The analysis revealed the following themes: (1) patient-centred care (PCC), which included 'understanding and involvement in the patient-as-person', 'establishment of a therapeutic alliance', and 'sharing power and responsibility'; and (2) biomedical (conventional) care, including the subthemes 'HCPs in power and control' and 'optimising medical outcomes, following guidelines'. Even though the elements of PCC were observed in several encounters, overall communication was not sufficiently fostering patient empowerment. Spending time with patients and building relations based on mutual trust seemed undervalued.

CONCLUSIONS

The results provide a broader understanding of how patients experience medication communication at hospital discharge. Both the patients and the HCPs appear to be inculcated with biomedical traditions and are uncertain about the roles and opportunities associated with PCC. Attention should be paid to patient preferences and to the core elements of the PCC model from admission to discharge to empower patients in medication self-management.

What Happens after Hospital Discharge? Deficiencies in Medication Management Encountered by Geriatric Patients with Polypharmacy

This study aimed to describe post-discharge medication self-management by geriatric patients with polypharmacy, to describe the problems encountered and to determine the related factors. In a multicenter study from November 2019 to March 2020, data were collected at hospital discharge and two to five days post-discharge. Geriatric patients with polypharmacy were questioned about medication management using a combination of validated (MedMaIDE) and self-developed questionnaires. Of 400 participants, 70% did self-manage medication post-discharge. Patients had a mean of four different deficiencies in post-discharge medication management (SD 2.17, range 0-10). Knowledge-related deficiencies were most common. The number of medicines and the in-hospital provision of medication management by nurses were significant predictors of post-discharge medication management deficiencies. In addition to deficiencies in knowledge, medication-taking ability and obtaining medication, non-adherence and disrupted continuity of medication self-management were common in geriatric patients with polypharmacy post-discharge. Improvements in in-hospital preparation could avoid medication self-management problems at home.

The processes of hospital discharge and recovery after blunt thoracic injuries: The patient's perspective

AIMS

The aim of this study was to explore hospital discharge processes and the self-management of recovery in the early post-discharge period after blunt thoracic injury from a patient perspective.

DESIGN

Qualitative interview study.

METHODS

Interviews were conducted with participants recruited from 8 sites across England and Wales between November 2019-May 2020. Semi-structured interviews were conducted between 5-8 weeks after hospital discharge, and in total, 14 interviews were undertaken. These interviews were recorded, transcribed and analysed using thematic coding.

RESULTS

Three main themes were identified from the analysis: (a) challenges in the discharge process, (b) coping at home after discharge and (c) managing medications at home. Pain was a dominant thread running throughout all themes which represented an important quality and safety concern for all participants. Associated concerns included insufficient preparation and education for hospital discharge, ineffective communication and subsequent unsafe use of opioids at home highlighting unmet patient care needs.

Discharge processes and medicines communication from the patient perspective: A qualitative study at an internal medicines ward in Norway

BACKGROUND

Patients are expected to participate in the hospital discharge process, assume self-management after discharge and communicate relevant information to their general practitioner; however, patients report that they are not being sufficiently empowered to take on these responsibilities. The aim of this study was to explore and understand the discharge process with a focus on medicines communication, from the patient perspective.

METHODS

Patients were included at a hospital ward, observed during health-care personnel encounters on the day of discharge and interviewed 1-2 weeks after discharge. A process analysis was performed, and a content analysis combined data from observations and data from patient interviews focusing on medicines communication in the discharge process.

RESULTS

A total of 9 patients were observed on the day of discharge, equalling 67.5 hours of observations. The analysis resulted in the following themes: (a) the observed discharge process; (b) patient initiatives; and (c) the patient role. The medicines communication in the discharge process appeared unstructured. Various patient preferences and needs were revealed. The elements of the best practice structured discharge conversation were observed; however, some patients did not have a discharge conversation at all.

CONCLUSIONS

The study contributes to a broader understanding of the discharge process, how patients experience it, including their role. It is evident that the discharge process is not always tailored to meet the patients' needs. More focus on early patient involvement and communication, in order to better prepare patients for self-management of their medications, is important for their health outcomes.

"The light at the end of the tunnel". Discharge experience of older patients with chronic diseases: A multi-centre qualitative study

AIM

To explore the experiences of being discharged from hospital of older patients with chronic diseases at time of discharge.

DESIGN

Multi-centre descriptive qualitative study.

METHODS

Semi-structured interviews were conducted with older patients with chronic diseases discharged from two Italian university hospitals, between March 2017 and October 2019. The interviews were audio-recorded, transcribed verbatim and analysed using inductive content analysis. Several strategies were used to ensure the credibility, dependability, confirmability, authenticity and transferability of the findings. The study was reported in accordance with Standards for Reporting Qualitative Research and Consolidated criteria for reporting qualitative research.

RESULTS

Sixty-five patients participated in the study. Six main categories emerged: feelings, need for information, time of fragility, need for support, need for trusting relationships, and home as a caring place.

CONCLUSION

Older patients with chronic diseases are patients who require quality discharge planning with a patient-centred care vision. Healthcare professionals should intervene more extensively and deeply in the discharge process, balancing the patients' perception of their needs against organizational priorities and the wish to return home with that of not being abandoned.

IMPACT

Discharge from hospital remains an area of concern as older people have varying degrees of met and unmet needs during and following hospital discharge. Discharge is characterized by conflicting feelings of patients, who need information and support of healthcare professionals through trusting and continuous relationships. Understanding the experience of discharge is essential to support older patients with chronic diseases, considering that discharge from hospital is not an end point of care but a stage of the process involving care transition. The reframing of discharge as another transition point is crucial for healthcare professionals, who will be responsible for making their patients fit for discharge by preparing them to manage their chronic condition at home.