The Post-discharge Process Is a Disservice to Patients and Providers

“I didn’t know what to do, so I came back,” said my in-the-dark patient.

He was calling me from the emergency department (ED), 5 days after I had discharged him from the hospital for an abdominal abscess. Although I was relieved to hear that his health hadn’t deteriorated and he instead went to the ED because he was unclear on the next steps in his care, I still felt terrible for him.

Here in the border city of El Paso, where the average median household income is almost $20,000 less than the national number, an avoidable return visit to the hospital can be a significant hardship. Many of my patients struggle to afford the thousand-plus dollars that an unplanned ED visit or inpatient readmission can cost and the hours away from work (read: lost wages) required.

Like many patients, he had difficulty understanding the complicated discharge instructions even before he left the hospital, never mind once he got home and developed some changes in his symptoms and condition. “Is this expected, or should I be worried?” “Nausea is a side effect of my antibiotic, but I need to take it for my infection… should I stop it, or do I need an anti-nausea medicine, too… or could this be something new or worse?” Due to the usual logistical issues and communication breakdowns, my patient never heard back from anyone about his questions, including me, and understandably grew more concerned. So he chose to do what seemed like the safest option: he returned to the ED.

Unfortunately, this is a common scenario for patients as they try to navigate an extremely complex healthcare journey, particularly after they are discharged from the ER or the hospital when they have often had major changes to their health and treatment plan. We know that discharged patients present both a significant risk (of complications and deterioration) and also a good opportunity for us to tend to their needs and follow through with delivering the quality care that they deserve. And we also know that there are a number of predictable factors that are responsible for adverse events; these include problems getting or taking the correct medications, being able to follow up as planned, or lack of awareness of which signs and symptoms indicate the need to seek further care quickly. And a significant number of these complications can be avoided. Nearly 30 percent of patient readmissions are preventable.

When patients we’ve cared for bounce back, it can reflect a setback for the patient. It also places an unnecessary strain on our already-strained resources. In our region for example, the El Paso hospitals are as overcrowded as ever – even more so. Today, the patients I see are sicker, with more serious conditions, than they were pre-pandemic; mostly because they deferred care during the pandemic. They require greater attention from my overburdened health care colleagues. Little of this is Covid, and most of it is delayed care and complications from people avoiding healthcare due to Covid and some of it is due to further erosion of human and financial resources.

But what if we did a better job of preparing patients to go home and care for themselves once they were there?

It sounds simple, but the post-discharge process has multiple moving parts, which makes it challenging to solve in its entirety. However, the vast majority of my patients would immediately benefit from improvements in two critical areas within this process: when we communicate with patients and how we do so.

As doctors and nurses, we know that the way we currently prepare patients for the transition home – a discharge conversation and post-discharge instructions – is not cutting it.

Despite both providers’ and patients’ well-intentioned efforts, many patients don’t remember the details of these critical conversations. And why should they? They are sick! And so happy to be going home many of the instructions go truly unheard. The importance of making a follow-up appointment or how to tend to a wound often does not land. One reason patients don’t absorb this information is because of our timing.

In the final hours of their hospital stay, my patients are often distracted with, and sometimes anxious about, the logistics of getting home. Furthermore, they are often in pain, upset, fatigued, or even partially sedated from the medications they were administered. Yet this is when we verbally download the details of their condition, the next steps in their care, new medications, and more. Regretfully, this can be an information-crammed conversation due to competing demands.

We need a better way. Instead of waiting until the day of discharge, we can increase patients’ understanding by talking with them as soon as they arrive and repeating critical points in shorter bursts throughout their stay.

A key strategy will be reworking the dense post-discharge plans and instructions that we hand patients upon leaving the hospital.

About half of patients report not grasping these walls of words across multiple pieces of paper. Sometimes that’s due to patients lacking the health literacy to decipher them, but it’s also because the materials don’t always make sense. This is another example of how our post-discharge process is a disservice to patients and those of us caring for them.

When I was recently discharged from the hospital, I was confused about what I needed to do next. If I can’t grasp the post-discharge instructions, how can I expect my patients to? Let’s rewrite these instructions to ensure they cover all the bases and that they’re easier for patients to follow. Shorter sentences. Narrative text. Everyday words.

Most crucially, though, we must communicate more when patients are most receptive to this how-to-recover information: once they’re back home.

Comfortable and at ease without the stimulation of a crowded hospital, patient after patient tells me that this is when they focus on getting better and questions crop up.

Patients wonder: Am I supposed to feel this sluggish? Does this new medication interfere with what I’m currently taking? When is my next appointment?

As these questions percolate in the first few days back home – the period when patients are most at risk of coming back to the hospital – and what do they get from us during this critical time period? Near radio silence.

Despite our desire to see our patients get better quickly, we increasingly don’t have the capacity to follow up with a phone call for several days – if at all. Many patients try to call for information, but they can have a tough time getting through. The whole disjointed process wears patients down.

Patient navigators can help by lessening the burden for everyone: patients, nurses, and physicians. From the moment a patient is admitted to the hospital, a “no-one-falls-through-the-cracks” navigator can be the single staff person responsible for their transition and recovery at home.

They can coordinate all the people and services patients need when they leave the hospital, whether from pharmacies, physicians’ offices, or social service agencies. And these navigators can work closely and pro-actively with patients to ensure they’re clear on instructions and feel confident about what comes next.

In my experience, this navigator support and reassurance prevents patients from falling off a care cliff when they leave the hospital and decreases their chance of bouncing back.

Another way to guide patients through the post-discharge process is to enable familiar, digital forms of communicating — like text or webchat.

Although 40 percent of my patients don’t answer their phones, they do respond to texts. We’ve already seen how automation can go beyond “Reply Y/N” to provide personalized information to patients, in a conversational way. AI is becoming a new way to help patients feel like they are engaged in a conversation with their provider (not a transaction) and get specific answers to their individual questions answered, quickly.

Similar to phone calls, the right texts at the right time can aid patients in their recovery and help avoid hospital readmittance. However, unlike old school phone calls, digital patient communications can be set up to require limited (or often no) manual effort from health care workers.

By combining some old-fashioned hand-holding (i.e., navigators) with some familiar technology, we could save patients and their loved ones needless worry, money and time. We could provide our health care workers with the space and hours to provide the quality care they want to give and protect them from burnout. And we could better ensure that our patients’ increasingly complex medical needs are met.

The status quo is not sustainable, and we can’t solve it all today. But let’s use straightforward communication strategies like these to keep financially vulnerable patients like mine healing safely (and less expensively) at home.

Photo: Tajuddin Molla, Getty Images

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