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.
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.
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.
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.