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Setting discharge goals

April 2010

How do you set discharge goals for a better transition of care back to the outpatient setting? That’s the big question that’s come up in a project I’m involved in at my hospital that aims to improve communication among care team members. That team includes providers, patients and family members.

We all know this tenet of hospital medicine: Discharge planning begins the moment the patient is admitted. (Some even argue that discharge planning begins the moment you hear a patient is getting admitted.) I’ve also heard it suggested that establishing discharge goals early in a hospitalization makes for better transitions of care and may reduce length of stay and hospital costs.

Setting discharge goals is also something basic that everyone can get his or her head around. Doctors may like to talk about patient satisfaction or length of stay or any of those other lovely numbers that administrators like to point to. But to a resident or nurse, those numbers may mean squat, while patients and families might find them downright confusing.

Figuring out how–and when–to communicate about what we’re trying to achieve by discharge is establishing clear guideposts that can direct everyone’s attention to the goal at hand: making an efficient, safe transition of care. Those goals provide some focus in our attention-deficit system (and my own personal ADD).

Now, before you roll your eyes because there is nothing new here, ask yourself this question: How many times have you gone into a patient’s room and said, “Mr. Smith, I think you’re ready to go home,” and Mr. Smith stares in utter astonishment, as if you’ve just told him he has two heads? Or the times you are ready to send someone home and she tells you she has to stay until 7 p.m. when her husband can come pick her up. If this has happened to you, read on.

In working on this project, we quickly realized that the question is not how to improve the discharge process; it is how to improve the hospitalization. The strategy is to establish discharge goals on admission that anyone–the family, nurses, cleaning crew and certainly doctors–can easily identify and say “OK, we’ve done this, this and this. I am ready to go home.”

Granted, the goals for a patient admitted with gastroenteritis and dehydration are pretty clear cut (goal #1: take PO well; #2: achieve appropriate urine output). But what about the 70-year-old with a CABG and abdominal pain? Or the 17-year-old with cystic fibrosis and shortness of breath? Or the patient with spina bifida and depression, who just won’t eat and has a UTI and infected decubitus ulcers? What are the discharge goals for these patients?

So, coming up with discharge goals can be challenging. But it can also help crystallize the rest of the hospitalization. These are not our discharge goals; they are the patient’s discharge goals. So the patient and family members need to be involved in the deliberations and help set the criteria.

We decided to write these goals on a separate sheet of paper, an easily accessible document that could be edited by anyone involved in the care of the patient, and then point out when goals are achieved. When all the discharge goals have been reached, the nurse pages the resident and the attending hospitalist to let them know that the patient is ready to go home.

We felt writing down the goals in a separate sheet makes it easy for all involved to see them. That way, the discharge goals are front and center during the entire hospitalization, something we can always refer to in explaining our actions and reactions. And when the discharge day comes, patients already know about it; after all, they’ve seen goals checked off and achieved. No more astonished looks, or questioning or doubtful stares.

So far, the project has hit a few snags–mostly from colleagues who think an extra sheet of paper is extra work, or who don’t see the need to clarify our goals when they should already be incorporated in our daily notes.

My answer is that this is not about us, it’s not about billing and it’s not about LOS. This is about communicating clearly with patients and their families and completely including them in their care. Yes, it is about family-centered care, a concept that, like it or not, is here to stay. And if we say we are family-centered, we better make sure we act family-centered.

Changing a group’s culture is always a challenge. Like Machiavelli said in “The Prince”: “There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.”

In future blogs I’ll let you know how this project goes, and when our efforts start bearing fruit…