The lack of coordination has consequences. Post-discharge medication errors are common, and necessary follow-up care and testing often don’t happen. The confusion and lack of information may contribute to high rehospitalization rates—another study, published in the New England Journal of Medicine earlier this month, found that as many as a third of Medicare patients are readmitted within 90 days, and a fifth within a month of being discharged.
A recent AARP Public Policy Institute survey of almost 2,500 patients with chronic medical conditions such as diabetes or arthritis found that nearly 20 percent said their transitional care was not well coordinated. The survey also found that those respondents were more likely to be readmitted to a health care facility within a month of discharge.
“The return home after a hospital stay, especially a prolonged one, can be stressful for individuals and their families,” says the accompanying report, “Chronic Care: A Call to Action for Health Reform.” The report says many older patients who leave the hospital with a chronic illness either do not receive or do not understand discharge instructions, treatment plans, medication regimes or follow-up instructions.
Albert Siu, M.D., professor and chairman of geriatrics at Mount Sinai School of Medicine in New York, says that over the last two decades he has seen a downward trend in continuity of care for older adults that spans a broad range of hospital transitions: from outpatient to hospital, hospital to outpatient and even within the hospital—with nurses and residents less likely to follow the same patient from day to day in the hospital.
So what does all this mean for the patient or caregiver trying to navigate this fragmented system?
“It means having a clear expectation when you leave the hospital of what should occur next, so that you can tell that something has fallen between the cracks and that needs to be corrected,” Siu says, adding that the lack of coordination means the caregiver role is more crucial than ever.
“Caregivers have to assume some of the role of patient advocate,” Siu says “and to educate themselves in the medical care that may need to occur after the hospital stay.”
How to Keep From Falling Through the Cracks
Drs. Siu and Sharma offer tips for patients leaving the hospital and for their caregivers:
* Ask whether the hospital doctor has contacted your primary care physician.
* Ask whether there’s any paperwork you can keep.
* Know whom to see for follow-up care.
* Ask how to schedule follow-up tests.
* Know when to start and stop medications.
* Ask about potential side effects of medications and whom to call if you experience them.
* Ask what signs or symptoms warrant a call or visit to the doctor’s office.
The Centers for Medicare & Medicaid Services offers a “Planning for Your Discharge” brochure with advice and checklists for preparing to leave a hospital, nursing home or other health care setting.
The Care Transitions Program, developed by Eric Coleman, M.D., and colleagues at the University of Colorado, has a discharge preparation checklist and other tools.