Transition of Care HCAHPS Questions

Failure to effectively communicate discharge instructions to patients can lead to hospital readmissions, missed appointments, unidentified side effects, overlooked symptoms and condition changes, and medication errors.

A recent study of patients surveyed at discharge indicated that 41% could not state their diagnosis, 37% could not state the purpose of their medications, and 86% could not identify the side effects of their medications. However, these problems may not be caused by a lack of patient education provided; it is often simply a lack of understanding by the patient. So, how can healthcare providers communicate more effectively?

Staff Education Video Sample

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In an “always culture”, when it comes to discharging patients, it’s all about effective and early communication. The staff education video will discuss specific skills and best practices to improve medical staff communication and patient understanding throughout a patient’s visit. Below are the two main transition of Care HCAHPS questions:

Did staff talk with you about whether you would have the help you needed when you left the hospital?
Did you get information in writing about symptoms and health problems to look for when you left the hospital?

Additionally, there are three yes-or-no questions that focus on the aspect of patients’ transition of care:

The hospital staff took my preferences and those of my family into account in deciding what my healthcare needs would be when I left the hospital.
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
When I left the hospital, I clearly understood the purpose of taking each of my medications.

While all of these questions deal with discharge, their primary focus is on communication. Communication on the help patients need, communication about the signs and symptoms to look for, communication on their preferences, their responsibilities, and understanding their medications.

General Concepts

Transition of Care HCAHPS questions So, how can healthcare providers and medical staff communicate more effectively? The first step is realizing that the main problem with the discharge process is that the process is designed for clinicians rather than for patients. Rather than waiting until the end of a patient’s stay, instructions should be clear, repetitive, and most importantly this communication should start from admission.

When building an always culture, identify a caregiver early; discuss plans, preferences, and goals for the patient’s discharge and continue to keep discharge planning as a topic of discussion throughout their stay. An “always culture” ensures patients have the education and the help they need to be confident in going home.

WRITTEN HEALTH INFORMATION
Patients receive information on everything from side effects, to medications, to procedures, to wound care; therefore, written backups are essential. These printed discharge materials are essential for patient education, and they should be referenced on the day of discharge and throughout their stay. Using these documents will standardize patient education across the hospital and promote continuity of care.

PATIENT & FAMILY PREFERENCES
Patients and their families need to be actively involved in discharge planning. As caregivers discover their patients’ needs and preferences, they can be written down on their communication board, and referenced throughout their stay. Sending patients and their families home with a plan that they helped design not only engages them in their own healthcare, it helps improve adherence to discharge instructions and leads to better health outcomes.

UNDERSTANDING RESPONSIBILITIES
Clear communication on a patient’s responsibilities when they return home is essential. In order to ensure patients understand their role in their own care, caregivers can employ the teach-back method—having patients repeat back their instructions and education. This technique will demonstrate any gaps in the patient’s understanding and give them confidence in going home.

MEDICATIONS
Before patients return home, they must have a clear understanding of what medications they are taking and why they are taking them. This should be reinforced, not just at discharge, but at every administration by telling the patient the name, dosage, purpose, and side effects for each medication.

PROCESS – 6 STEPS
Start with the end in mind, by keeping the idea of returning home a constant point of conversation. On the day of discharge, caregivers can use the discharge paperwork and follow the 6 points of education: reviewing the patient’s diagnosis, test results, treatments received, follow-up appointments, symptoms to watch for, and medications. These subjects should also be incorporated into discussions and education throughout their stay in order to keep the transition of care in the front of their minds.

Download a PDF Summary

Download a summary of the Communication on Medications video and the tactics used to address specific HCAHPS survey questions.

Patient Education Video Sample

Watch this short sample of the Always Culture patient education video on Discharge and Transition of Care

Preview the Spanish version.

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See our Patient Education Videos

When a patient leaves the hospital, there are a lot of things to remember: follow-up appointments, the proper utilization of medical devices, and instructions for medications. Therefore, it is critical that patients are provided with the information and help they need. The patient video helps prepare patients for their departure, and sets expectations on the measures that medical staff will take to ensure they feel confident in returning home.

By proactively addressing the patient’s plans for going home, medical staff can make sure all preferences are heard, questions and concerns are addressed, follow-up care is arranged, and medication instructions and purposes are clear. This is not only a key part of creating a positive patient experience, but it is necessary for adherence to education and for optimal health outcomes.

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