Bridging the Gap Between Hospital Discharge and Community Essay

Readmissions to the hospital has been projected to cost the U. S. approximately 17 billion dollars annually, of which 90% of those readmitted were unplanned (Weiss, Yakusheva, and Bobay, 2011). For those patients who have a primary care provider and actually follow up as instructed within 1-2 weeks, 2/3 of those primary care providers will have not received a written discharge summary of the patient’s stay.

On the other hand, a large percentage of patients either do not have access to primary care and if they do, they fail to follow up within 1-2 weeks after hospital discharge as instructed. This may may be the cause of a number of different loopholes, the biggest of which is inadequate communication and education.

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The quality committee has worked closely with the hospital’s team of physicians and other providers as well as all nursing departments, ancillary department’s and all relevant nonclinical staff to propose the funding of a department, staffed by experienced registered nurses, who will be the key players responsible of bridging the gap between hospital and community providing discharge instructions, education and will follow the patient in the weeks coming after they leave the hospital ensuring access to medications and appropriate follow ups.

The purpose of this program is to significantly reduce the number of readmissions that are related to ineffective discharge planning and/or poor education. The transition team will consult on every admitted patient in the hospital to assess their ability to effectively transition into the community setting after discharge.

Those who have adequate resources, established relationships with primary care, and do not require any social work assistance, the team will still provide a comprehensive discharge planning evaluation, education, and an evaluation of their understanding of the steps to take as soon as they leave our building. Each patient will be given a score based on his or her evaluation that will be associated with a risk level.

This score will coincide with the details on how often and for how long the team will have direct communication with the patient after discharge, but even the lowest risk for interruption will still be contacted two times by the staff for reassessment. On the other hand, for those patients who have not established a relationship with a primary care provider, one of the primary goals of the transition team while the patient is in the hospital is to initiate a referral to a PCP and ensure they have made contact with the patient prior to discharge.

The physician department is addressing the specifics of the details on their end, but there will be some sort of call or rotation for those patients who are not independently resourced to have access to follow up care after discharge. Part of this plan proposes that the hospital be responsible for a portion of the cost of follow up visits seeing as how current literature estimates the cost of providing community follow up is substantially lower than the cost the hospital will eat for their readmission.

Other benefits the transition team will provide include a 24 hour number for patients to call with questions or concerns, a lifetime connection to education materials and community resources for health promotion and disease prevention, and an intimate relationship with case management and social work to help provide assistance with medications, transportation, and financial concerns regarding housing or other essential expenses after discharge. In a study done evaluating hospital discharge, the authors are concerned that poor discharge coordination jeopardizes patient safety and results in substandard medical care. With shorter hospitalizations and high patient loads for both physicians and nurses, discharge planning is often hurried and incomplete” (Balaban, Weissman, Samuel, and Woolhandler, 2008).

After reviewing national surveys regarding hospital discharge, they found that only 50% of patients with congestive heart failure received any sort of written instructions at the time of discharge. Other information revealed most patients were unaware of their discharge diagnosis, misunderstand the use of new medications, and receive insufficient discharge care, all of which are major contributors to hospital readmissions (Balaban et al. 2008). They proposed a similar model with the same goals and their findings supported the use of some sort of designated discharge coordination that connects the hospital and community, they were able to divert a significant number of revisits to the hospital for issues that had already been addressed and patients were simply uneducated regarding their condition or proposed treatment plan. Another study where the hospital set up an actual discharge clinic reported that in the first six months of operation they were able to “reduce emergency room visits and readmissions for targeted patients by 68%” (Beresford, 2011).

Although there has not been enough time to allow for comprehensive analysis of the cost reduction benefits, what we know about government proposals for hospital and physician reimbursement that have already begun to take effect and the reality that according to the 2011 Comparative Price Report on medical hospital fees by country, the U. S ranked top of the list for cost of an average hospital stay at $15,734. 00, the financial rationale supporting this program is that its overall funding will be markedly lower than per patient readmissions and the benefits substantially greater (McMahon, 2012).

However, with the implementation of the program, we will provide an ongoing study for the first 12 months documenting the results of the transition team’s intervention that notes primary care follow ups, patients perceptions of receiving adequate discharge instructions, and preventable number of readmissions. As we all know that “reasons for readmission are multifactorial and influenced by complex and interacting comorbidities, many readmissions within 30 days are viewed as preventable and considered failures of discharge processes (Weiss et al. 2011). This is our opportunity to provide a service to our patients that will change that outcome, and continue to promote excellence in service and in business in our organization. Beresford, 2011, points out that we can “look at this as a way for the hospital to have fewer costly unreimbursed bounce backs,” which he notes “is a win-win for everyone. ” The goal here is to address underlying reasons for the national healthcare crisis in an attempt to change the culture for the long-term benefits of the organization.

There may be less complex and seemingly more affordable ideas, but in the end applying a patch in the hole is temporary, and eventually the whole tire has to be replaced.


Balaban, R. , Weissman, J. , Samuel, P. , & Woolhandler, S. (2008). Redefining and redesigning hospital discharge to enhance patient care: A randomized controlled study. Journal of General Internal Medicine, 23(8), 1228-1233. Retrieved from http://www. ncbi. nlm. nih. gov/pmc/articles/PMC2517968/ Beresford, L. (2011). Is a post discharge clinic in your hospital’s future? The Hospitalist. Retrieved from


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