Understanding and execution of discharge instructions.

Discharge from the acute care hospital is increasingly recognized as a time of heightened vulnerability for lapses in safety and quality. The capacity of patients to understand and execute discharge instructions is critical to promote effective self-care. This study explores factors that predict understanding and execution of discharge instructions in a sample of 237 recently discharged older adults. A study nurse conducted a postdischarge home visit to ascertain patient understanding and assess execution of instructions. Health literacy, cognition, and self-efficacy were important predictors of successful understanding and execution of instructions. Neither discharge diagnosis nor complexity of discharge instructions was found to be a significant predictor of these outcomes. Results indicate a need to implement reliable protocols that identify patients at risk for poor understanding and execution of hospital discharge instructions and provide customized approaches to meet them at their respective levels.

Better transitions: improving comprehension of discharge instructions.

Discharge out of the hospital is a time of heightened vulnerability for our patients. The combination of shorter lengths of stay and increased clinical acuity results in increased complexity of discharge instructions and higher expectations for patients to perform challenging self-care activities. Yet, the amount of time and resources available for patient and family caregiver preparation prior to discharge has not significantly changed commensurate with these new demands. Inadequate health literacy and unrecognized cognitive impairment are two important contributing factors. In this article we discuss the effects of health literacy and cognitive impairment on patient comprehension of discharge instructions, how this may impact the frequency of adverse events after they leave the hospital, and likelihood of readmission, and offer an evidence-based prototype for how to address the problem.

Further application of the care transitions intervention: results of a randomized controlled trial conducted in a fee-for-service setting.

The study objective was to test whether a self-care model for transitional care that has been demonstrated to improve outcomes in Medicare Advantage populations--The Care Transitions Intervention--could also improve outcomes in a Medicare fee-for-service population. Intervention patients were less likely to be readmitted to a hospital in general and for the same condition that prompted their index hospitalization at 30, 90, and 180 days versus control patients. Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rate of subsequent rehospitalization in a Medicare fee-for-service population.

The central role of performance measurement in improving the quality of transitional care.

The objectives of this study were: (1) to demonstrate the ability of the Care Transitions Measure (CTM) to identify care deficiencies; (2) to devise and implement a quality improvement approach designed to remedy these deficiencies; (3) to assess the impact of the quality improvement approach on CTM scores; and (4) to test whether the CTM-3 predicts return to the emergency department. The CTM was found to be a sensitive tool able to capture changes in performance. The 3-item CTM was found to significantly predict post-hospital return to the emergency department within the first 30 days (p = 0.004).