Ryan S. Greysen, MD, MHS

Thirty‐six million adults were discharged from US hospitals in 2012, with approximately 45% from medicine service lines.[1, 2] Discharge planning, a key aspect of care for hospitalized patients,[3] should involve the development of a plan to enable the patient to be discharged at the appropriate time and with provision of sufficient postdischarge support and services.[4]

Central to the discharge planning process is an assessment of a patient's readiness for discharge. Readiness is often a provider‐driven process, based on specific clinical and health system benchmarks.[5] However, providers' perception of readiness for discharge does not always correlate with patients' self‐assessments or objective measures of understanding.[6] For example, nurses overestimate patients' readiness for discharge compared to patients' own self‐report.[7] As a result, the need to include the patient perspective is increasingly recognized as an important contributing factor in the discharge planning process.[8, 9]

Current approaches to assessing discharge readiness are typically single assessments. However, these assessments do not take into account the complexity of discharge planning or patients' understanding, or their ability to carry out postacute care tasks.[8] In addition, few models have included assessments of physical stability and functional ability along with measures such as ability to manage self‐care activities at home, coping and social support, or access to health system and community resources.[10, 11]

To address these gaps in the existing literature, we carried out a prospective observational study of daily, patient‐reported, assessments of discharge readiness to better understand patients' perspectives on issues that could impede the transition to home. Using these data, we then sought to determine the prevalence of patient‐reported discharge barriers and the frequency with which they were resolved prior to the day of discharge. We also explored whether problems identified at discharge were associated with 30‐day readmission.

METHODS

RESULTS

DISCUSSION

Assessing discharge readiness highlights an opportunity to engage patients directly in their discharge planning process. However, our prospective study of 163 hospitalized adults revealed that unresolved discharge barriers were common; 90% of patients were discharged with at least 1 issue that might inhibit an effective transition home. The majority of these patients were also discharged home without any support services. In addition, many of the major barriers patients reportedpain, lack of understanding around plans, and ability to provide self‐carewere consistent from admission to discharge, suggesting a missed opportunity to address problems present early in a patient's stay.

Some of the issues our patients described, such as pain; lack of understanding of a recovery plan; and functional, social, and environmental vulnerabilities that impede recovery, have been described in studies using data collected in the postacute time period.[13, 14, 15] Focus on postacute barriers is likely to be of limited clinical utility to assist in any real‐time discharge planning, particularly planning that assesses individual patients' needs and tailors programs and education appropriately. Having said this, consistency between our results and data collected from postdischarge patients again supports broad areas of improvement for health systems.

Persistent gaps in care at discharge may be a result of limited standardization of discharge processes and a lack of engagement in obtaining patient‐reported concerns. Lack of a framework for preparing individual patients for discharge has been recognized as a significant obstacle to effective discharge planning. For example, Hesselink et al.'s qualitative study with almost 200 patients and providers across multiple institutions described how lack of a standard approach to providing discharge planning resulted in gaps in information provision.[16] Similarly, Horwitz et al. described wide variation in discharge practices at a US academic medical center, suggesting lack of a standard approach to identifying patient needs.[14]

Although many transitions of care programs have supported implementation of specific care interventions at a hospital or health system level, there have been surprisingly few studies describing efforts to standardize the assessment of discharge barriers and prospectively engage individual patients.[17] One emblematic study used stakeholder interviews and process mapping to develop a readiness report within their electronic medical record (EMR).[17] Aggregate data from the EMR including orders and discharge plans were coded, extracted, and summarized into a report. The overall goal of the report was to identify progress toward completion of discharge tasks; however, a limitation was that it did not explicitly include patient self‐assessments. Another study by Grimmer et al. describes the development of a patient‐centered discharge checklist that incorporated patients and care concerns.[18] The themes incorporated into this checklist cover many transitional issues; however, outside of the checklist's development, few publications or Web resources describe it in actual use.

Our approach may represent an advance in approaches to engaging patients in discharge planning and preparing patients for leaving the hospital. Although our data do not support efficacy of our daily surveys in terms of improving discharge planning, this initial evaluation provides the framework upon which providers can develop discharge plans that are both standardized in terms of using a structured multidomain communication tool to elicit barriers, as well as patient‐centered and patient‐directed, by using the information collected in the survey tool to initiate tailored discharge planning earlier in the hospital stay. However, our program points out an important limitation of an entirely patient‐initiated program, which is difficulty obtaining truly daily assessments. During this study, we had a single research assistant visit patients as frequently as possible during hospitalization, but even daily visits did not yield complete information on all patients. Although this limitation may in part be due to the fact that our study was a focused pilot of an approach we hope to expand, it also represents the complexity of patient experience in the hospital, where patients are often out of their room for tests, are unable to complete a survey because of problematic symptoms, or simply are unwilling or unable to participate in regular surveys.

Our study has a number of limitations. First, the number of patients in our study overall, and the number who completed at least 2 surveys, was relatively small, limiting the generalizability of the study and our ability to determine the true prevalence of unresolved barriers at discharge. In addition, our selection criteria and response rates have limited our sample in that our final group may not be representative of all patients admitted to our medicine service. The broad exclusion of patients who had physical or psychosocial barriers, and those who were acutely unwell and symptomatic, has the potential to introduce selection bias given the excluded populations are those most at risk of readmission. We also acknowledge that some of the issues that patients' are reporting may be chronic ones. However, given the fact that patients feel these issues, even if chronic, are unaddressed or that they want to talk with their doctor about them, is still a very large potential gap in care and patient engagement.

However, despite these limitations, which seem most likely to produce a cohort that is more likely to be able to participate in our survey, and in turn more likely to participate in their care more broadly, we still observed disappointing resolution of discharge barriers. In addition, our adapted survey instrument, though based on well‐supported conceptual frameworks,[19] has not been extensively tested outside of our hospital setting. Finally, as a single‐center study, our results cannot be generalized to other settings.

Assessing discharge readiness highlights an opportunity to obtain patient self‐reported barriers to discharge. This can facilitate discharge planning that targets individual patient needs. This information also emphasizes potentially fruitful opportunities for improved communication and education activities, potentially if these data are fed back to providers in real time, potentially as part of team‐based dashboards or the context of interdisciplinary team models.

Thirty‐six million adults were discharged from US hospitals in 2012, with approximately 45% from medicine service lines.[1, 2] Discharge planning, a key aspect of care for hospitalized patients,[3] should involve the development of a plan to enable the patient to be discharged at the appropriate time and with provision of sufficient postdischarge support and services.[4]

Central to the discharge planning process is an assessment of a patient's readiness for discharge. Readiness is often a provider‐driven process, based on specific clinical and health system benchmarks.[5] However, providers' perception of readiness for discharge does not always correlate with patients' self‐assessments or objective measures of understanding.[6] For example, nurses overestimate patients' readiness for discharge compared to patients' own self‐report.[7] As a result, the need to include the patient perspective is increasingly recognized as an important contributing factor in the discharge planning process.[8, 9]

Current approaches to assessing discharge readiness are typically single assessments. However, these assessments do not take into account the complexity of discharge planning or patients' understanding, or their ability to carry out postacute care tasks.[8] In addition, few models have included assessments of physical stability and functional ability along with measures such as ability to manage self‐care activities at home, coping and social support, or access to health system and community resources.[10, 11]

To address these gaps in the existing literature, we carried out a prospective observational study of daily, patient‐reported, assessments of discharge readiness to better understand patients' perspectives on issues that could impede the transition to home. Using these data, we then sought to determine the prevalence of patient‐reported discharge barriers and the frequency with which they were resolved prior to the day of discharge. We also explored whether problems identified at discharge were associated with 30‐day readmission.

METHODS

RESULTS

DISCUSSION

Assessing discharge readiness highlights an opportunity to engage patients directly in their discharge planning process. However, our prospective study of 163 hospitalized adults revealed that unresolved discharge barriers were common; 90% of patients were discharged with at least 1 issue that might inhibit an effective transition home. The majority of these patients were also discharged home without any support services. In addition, many of the major barriers patients reportedpain, lack of understanding around plans, and ability to provide self‐carewere consistent from admission to discharge, suggesting a missed opportunity to address problems present early in a patient's stay.

Some of the issues our patients described, such as pain; lack of understanding of a recovery plan; and functional, social, and environmental vulnerabilities that impede recovery, have been described in studies using data collected in the postacute time period.[13, 14, 15] Focus on postacute barriers is likely to be of limited clinical utility to assist in any real‐time discharge planning, particularly planning that assesses individual patients' needs and tailors programs and education appropriately. Having said this, consistency between our results and data collected from postdischarge patients again supports broad areas of improvement for health systems.

Persistent gaps in care at discharge may be a result of limited standardization of discharge processes and a lack of engagement in obtaining patient‐reported concerns. Lack of a framework for preparing individual patients for discharge has been recognized as a significant obstacle to effective discharge planning. For example, Hesselink et al.'s qualitative study with almost 200 patients and providers across multiple institutions described how lack of a standard approach to providing discharge planning resulted in gaps in information provision.[16] Similarly, Horwitz et al. described wide variation in discharge practices at a US academic medical center, suggesting lack of a standard approach to identifying patient needs.[14]

Although many transitions of care programs have supported implementation of specific care interventions at a hospital or health system level, there have been surprisingly few studies describing efforts to standardize the assessment of discharge barriers and prospectively engage individual patients.[17] One emblematic study used stakeholder interviews and process mapping to develop a readiness report within their electronic medical record (EMR).[17] Aggregate data from the EMR including orders and discharge plans were coded, extracted, and summarized into a report. The overall goal of the report was to identify progress toward completion of discharge tasks; however, a limitation was that it did not explicitly include patient self‐assessments. Another study by Grimmer et al. describes the development of a patient‐centered discharge checklist that incorporated patients and care concerns.[18] The themes incorporated into this checklist cover many transitional issues; however, outside of the checklist's development, few publications or Web resources describe it in actual use.

Our approach may represent an advance in approaches to engaging patients in discharge planning and preparing patients for leaving the hospital. Although our data do not support efficacy of our daily surveys in terms of improving discharge planning, this initial evaluation provides the framework upon which providers can develop discharge plans that are both standardized in terms of using a structured multidomain communication tool to elicit barriers, as well as patient‐centered and patient‐directed, by using the information collected in the survey tool to initiate tailored discharge planning earlier in the hospital stay. However, our program points out an important limitation of an entirely patient‐initiated program, which is difficulty obtaining truly daily assessments. During this study, we had a single research assistant visit patients as frequently as possible during hospitalization, but even daily visits did not yield complete information on all patients. Although this limitation may in part be due to the fact that our study was a focused pilot of an approach we hope to expand, it also represents the complexity of patient experience in the hospital, where patients are often out of their room for tests, are unable to complete a survey because of problematic symptoms, or simply are unwilling or unable to participate in regular surveys.

Our study has a number of limitations. First, the number of patients in our study overall, and the number who completed at least 2 surveys, was relatively small, limiting the generalizability of the study and our ability to determine the true prevalence of unresolved barriers at discharge. In addition, our selection criteria and response rates have limited our sample in that our final group may not be representative of all patients admitted to our medicine service. The broad exclusion of patients who had physical or psychosocial barriers, and those who were acutely unwell and symptomatic, has the potential to introduce selection bias given the excluded populations are those most at risk of readmission. We also acknowledge that some of the issues that patients' are reporting may be chronic ones. However, given the fact that patients feel these issues, even if chronic, are unaddressed or that they want to talk with their doctor about them, is still a very large potential gap in care and patient engagement.

However, despite these limitations, which seem most likely to produce a cohort that is more likely to be able to participate in our survey, and in turn more likely to participate in their care more broadly, we still observed disappointing resolution of discharge barriers. In addition, our adapted survey instrument, though based on well‐supported conceptual frameworks,[19] has not been extensively tested outside of our hospital setting. Finally, as a single‐center study, our results cannot be generalized to other settings.

Assessing discharge readiness highlights an opportunity to obtain patient self‐reported barriers to discharge. This can facilitate discharge planning that targets individual patient needs. This information also emphasizes potentially fruitful opportunities for improved communication and education activities, potentially if these data are fed back to providers in real time, potentially as part of team‐based dashboards or the context of interdisciplinary team models.

Thirty‐six million adults were discharged from US hospitals in 2012, with approximately 45% from medicine service lines.[1, 2] Discharge planning, a key aspect of care for hospitalized patients,[3] should involve the development of a plan to enable the patient to be discharged at the appropriate time and with provision of sufficient postdischarge support and services.[4]

Central to the discharge planning process is an assessment of a patient's readiness for discharge. Readiness is often a provider‐driven process, based on specific clinical and health system benchmarks.[5] However, providers' perception of readiness for discharge does not always correlate with patients' self‐assessments or objective measures of understanding.[6] For example, nurses overestimate patients' readiness for discharge compared to patients' own self‐report.[7] As a result, the need to include the patient perspective is increasingly recognized as an important contributing factor in the discharge planning process.[8, 9]

Current approaches to assessing discharge readiness are typically single assessments. However, these assessments do not take into account the complexity of discharge planning or patients' understanding, or their ability to carry out postacute care tasks.[8] In addition, few models have included assessments of physical stability and functional ability along with measures such as ability to manage self‐care activities at home, coping and social support, or access to health system and community resources.[10, 11]

To address these gaps in the existing literature, we carried out a prospective observational study of daily, patient‐reported, assessments of discharge readiness to better understand patients' perspectives on issues that could impede the transition to home. Using these data, we then sought to determine the prevalence of patient‐reported discharge barriers and the frequency with which they were resolved prior to the day of discharge. We also explored whether problems identified at discharge were associated with 30‐day readmission.

METHODS

RESULTS

DISCUSSION

Assessing discharge readiness highlights an opportunity to engage patients directly in their discharge planning process. However, our prospective study of 163 hospitalized adults revealed that unresolved discharge barriers were common; 90% of patients were discharged with at least 1 issue that might inhibit an effective transition home. The majority of these patients were also discharged home without any support services. In addition, many of the major barriers patients reportedpain, lack of understanding around plans, and ability to provide self‐carewere consistent from admission to discharge, suggesting a missed opportunity to address problems present early in a patient's stay.

Some of the issues our patients described, such as pain; lack of understanding of a recovery plan; and functional, social, and environmental vulnerabilities that impede recovery, have been described in studies using data collected in the postacute time period.[13, 14, 15] Focus on postacute barriers is likely to be of limited clinical utility to assist in any real‐time discharge planning, particularly planning that assesses individual patients' needs and tailors programs and education appropriately. Having said this, consistency between our results and data collected from postdischarge patients again supports broad areas of improvement for health systems.

Persistent gaps in care at discharge may be a result of limited standardization of discharge processes and a lack of engagement in obtaining patient‐reported concerns. Lack of a framework for preparing individual patients for discharge has been recognized as a significant obstacle to effective discharge planning. For example, Hesselink et al.'s qualitative study with almost 200 patients and providers across multiple institutions described how lack of a standard approach to providing discharge planning resulted in gaps in information provision.[16] Similarly, Horwitz et al. described wide variation in discharge practices at a US academic medical center, suggesting lack of a standard approach to identifying patient needs.[14]

Although many transitions of care programs have supported implementation of specific care interventions at a hospital or health system level, there have been surprisingly few studies describing efforts to standardize the assessment of discharge barriers and prospectively engage individual patients.[17] One emblematic study used stakeholder interviews and process mapping to develop a readiness report within their electronic medical record (EMR).[17] Aggregate data from the EMR including orders and discharge plans were coded, extracted, and summarized into a report. The overall goal of the report was to identify progress toward completion of discharge tasks; however, a limitation was that it did not explicitly include patient self‐assessments. Another study by Grimmer et al. describes the development of a patient‐centered discharge checklist that incorporated patients and care concerns.[18] The themes incorporated into this checklist cover many transitional issues; however, outside of the checklist's development, few publications or Web resources describe it in actual use.

Our approach may represent an advance in approaches to engaging patients in discharge planning and preparing patients for leaving the hospital. Although our data do not support efficacy of our daily surveys in terms of improving discharge planning, this initial evaluation provides the framework upon which providers can develop discharge plans that are both standardized in terms of using a structured multidomain communication tool to elicit barriers, as well as patient‐centered and patient‐directed, by using the information collected in the survey tool to initiate tailored discharge planning earlier in the hospital stay. However, our program points out an important limitation of an entirely patient‐initiated program, which is difficulty obtaining truly daily assessments. During this study, we had a single research assistant visit patients as frequently as possible during hospitalization, but even daily visits did not yield complete information on all patients. Although this limitation may in part be due to the fact that our study was a focused pilot of an approach we hope to expand, it also represents the complexity of patient experience in the hospital, where patients are often out of their room for tests, are unable to complete a survey because of problematic symptoms, or simply are unwilling or unable to participate in regular surveys.

Our study has a number of limitations. First, the number of patients in our study overall, and the number who completed at least 2 surveys, was relatively small, limiting the generalizability of the study and our ability to determine the true prevalence of unresolved barriers at discharge. In addition, our selection criteria and response rates have limited our sample in that our final group may not be representative of all patients admitted to our medicine service. The broad exclusion of patients who had physical or psychosocial barriers, and those who were acutely unwell and symptomatic, has the potential to introduce selection bias given the excluded populations are those most at risk of readmission. We also acknowledge that some of the issues that patients' are reporting may be chronic ones. However, given the fact that patients feel these issues, even if chronic, are unaddressed or that they want to talk with their doctor about them, is still a very large potential gap in care and patient engagement.

However, despite these limitations, which seem most likely to produce a cohort that is more likely to be able to participate in our survey, and in turn more likely to participate in their care more broadly, we still observed disappointing resolution of discharge barriers. In addition, our adapted survey instrument, though based on well‐supported conceptual frameworks,[19] has not been extensively tested outside of our hospital setting. Finally, as a single‐center study, our results cannot be generalized to other settings.

Assessing discharge readiness highlights an opportunity to obtain patient self‐reported barriers to discharge. This can facilitate discharge planning that targets individual patient needs. This information also emphasizes potentially fruitful opportunities for improved communication and education activities, potentially if these data are fed back to providers in real time, potentially as part of team‐based dashboards or the context of interdisciplinary team models.