What are the best practices for transitioning patients from hospital to home?

1 Assess patient needs

The first step in planning a transition of care is to assess the patient's needs, preferences, and goals. This involves conducting a comprehensive evaluation of the patient's medical, social, psychological, functional, and environmental factors that may affect their recovery and quality of life. You should also involve the patient and their family or caregivers in the assessment process and discuss their expectations and concerns. Based on the assessment, you can identify the appropriate level and type of care, services, and support that the patient will need after discharge.

3 Coordinate with the care team

The third step is to coordinate with the care team to ensure that the patient's care plan is implemented and communicated effectively. The care team may consist of various professionals, such as physicians, nurses, therapists, pharmacists, social workers, and home health aides. You should establish clear roles and expectations for each member of the care team and facilitate regular communication and collaboration. You should also verify that the patient's medical records, prescriptions, equipment, and supplies are ready and transferred to the next care setting.

4 Educate the patient and caregiver

The fourth step is to educate the patient and caregiver about the patient's condition, treatment, and self-care. Education is essential for empowering the patient and caregiver to manage the patient's health and prevent readmissions. You should use teach-back methods, such as asking the patient and caregiver to repeat or demonstrate what they have learned, to confirm their understanding and address any knowledge gaps. You should also provide them with written materials, such as discharge instructions, medication lists, and contact information, that they can refer to at home.

5 Follow up after discharge

The fifth step is to follow up with the patient and caregiver after discharge to monitor their progress and satisfaction. Follow-up can be done through phone calls, home visits, or telehealth platforms, depending on the patient's needs and preferences. You should check if the patient and caregiver have any questions or concerns, if they have received the necessary services and support, if they have adhered to the care plan and medications, and if they have experienced any adverse events or changes in their condition. You should also coordinate with the post-discharge care providers and settings to ensure continuity and quality of care.

6 Evaluate and improve the transition process

The sixth step is to evaluate and improve the transition process based on the feedback and outcomes of the patient and the care team. Evaluation can help you identify the strengths and weaknesses of the transition process, as well as the opportunities and challenges for improvement. You should use standardized tools and measures, such as patient satisfaction surveys, readmission rates, and quality indicators, to assess the effectiveness and efficiency of the transition process. You should also solicit and incorporate the input and suggestions of the patient, caregiver, and care team to enhance the transition process.