The Agency for Healthcare Research and Quality, Patient Safety Network, shares a web case study to emphasize that the period following discharge from the hospital is an especially vulnerable time for patients. Hospitalizations have become progressively shorter despite the increasing complexity of patients, and as a result, patients are often discharged with ongoing care needs. The quality of the discharge process and effective transitions of care are critical in minimizing gaps in care and preventing unnecessary hospital readmissions.
The Case Study tells the sad, but unfortunately common, story of a 78 year-old veteran who was a victim of discontinuity of care. The patient’s care and, more significantly, his advanced care planning (ACP) discussions were fragmented across multiple admissions and care settings from the hospital to the SNF. While the SNF in this case should be commended for their efforts to develop an ACP for this patient with limited capacity, unfortunately, they failed to document and write orders for hospice in the chart leaving the nursing staff no option but to send the patient to the hospital when he experienced acute respiratory failure. Clear communication and most importantly, timely documentation were critical for this medically complex patient who needed frequent hospitalizations. Because such communication was lacking, the quality of care was compromised.
- Advanced care planning should be implemented and documented in a timely manner, updated as conditions change, and shared across transitions.
- High-quality patient care requires well-coordinated transitions of care with clear communication between care facilities. Optimal transitions are critical for high-risk patients who are transferred between SNFs and hospitals.
- Direct communication complements documented communication (e.g., EHR) and is necessary for patients who are going through palliative care transitions.
- Partnerships between hospitals and surrounding SNFs are an effective way to reduce communication barriers.
Source: Preventable Transfer to the Hospital; Garima Agrawal, MD, MPH, Pouria Kashkouli, MD, MS, and and Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA | July 8, 2022