The Importance of Engaging Patients and Family Members in the Discharge Process

This is part 1 of 3 blog posts focusing on the journey of patient experience and outcome improvement at Lutheran Medical Center.

How does your organization engage the patient and family members in the discharge process?  Do you do a teach back to check for understanding?  Do you use an assessment tool to measure the patient’s comfort with going home?  Or do you tend to print off a bunch of papers, maybe hand them some photo copies, and then wish them luck?  What do patients do if they have concerns?  

These are the questions that I, alongside staff members at Lutheran Medical Center, addressed on a webinar sponsored by the Colorado Hospital Association on increasing patient and family engagement in the discharge process.  This topic is especially relevant as consumerism rises in healthcare and regulations encourage providers to focus on higher quality of care, patient satisfaction, and the value they are providing.

During the webinar, I presented background information on three successful care transition models, highlighting the tools they encourage providers to utilize in engaging patients and families:

  • Care Transitions Initiative ®
  • Project Red
  • Project Boost®

The Care Transitions Initiative leverages a self-management model through a Transitions Coach.  It also uses several assessment tools, including the Patient Activation Assessment, the Family Caregiver Activation Assessment, DECAF, and has a set of Care Transitions Measures (CTM-15).  Eric Coleman at the University of Colorado is the lead researcher.

Project RED (Re-engineering Discharge) recommends 12 mutually reinforcing components, including patient call backs, teach backs and an easy to understand After Hospital Care Plan.   

Project Boost (Better Outcomes by Optimizing Safe Transitions) was created as a quality improvement project by the Society of Hospital Medicine.  It has a number of great tools to use to assess the patient’s readiness for discharge (General Assessment of Preparedness).

The key to these approaches is they have a strong patient/family engagement strategy with specific recommended tools for assessing the level of patient comprehension and engagement. These approaches are critical, because when patients are worried about finances or are scared, they may not fully understand the resources at their disposal to alleviate stress and properly care for themselves or loved ones. By implementing any of these initiatives, hospitals can empower patients by reducing miscommunication and uncertainty.

Although patient engagement strategies are essential to improving outcomes, they can be challenging to thoroughly implement without significantly disrupting nurse work flow or the efficiency of a team. However, technology solutions can help circumvent work flow hurdles. After learning about the benefits of using technology as a care team asset, Lutheran Medical Center decided to implement a CipherOutreach. By adding yet another patient-facing touchpoint, Lutheran proved their dedication to their patients’ well-being and the human element of care.

To learn more about Lutheran’s patient engagement journey, look for our second blog post in the series.

Barb Davis

Barbara Davis, MA has been involved in quality in healthcare for over 30 years, and currently serves as CipherHealth's SVP of Clinical Services. She has worked in complex health care environments, including a university health system, an HMO health plan, and multi-hospital system. Her areas of expertise include quality improvement and Lean, service excellence focusing on organizational culture and the patient experience, patient safety and reliability, regulatory issues and organizational strategic goal setting. Currently she sits on the Patient and Family Advisory Council at Saint Joseph Hospital in Denver.