7 recommendations to improve care coordination

1. Review new and changed medications prior to discharge. Here's a helpful strategy:

Make medication review part of the discharge process
Case studies:
- Addison Gilbert Hospital and Beverly Hospital
- Beth Israel Deaconess Hospital - Milton

2. Develop a standardized discharge process. Use these two strategies:

Use a checklist
A checklist will help ensure each step of the discharge process is completed.

Case study:
- Boston Children's Hospital
Additional resources:
- Patient Discharge Care Coordination Checklist (Stratis Health)
Develop a standardized discharge form
Use a standardized discharge form for patients who are headed home.

Case study:
- Boston Children's Hospital

3. Ensure that patients and their caregivers receive effective education. Here are 2 strategies:

Use the teach-back method
Use the teach-back method to help ensure patient and family comprehension of the most important elements of their discharge instructions.

Case studies:
- Boston Children's Hospital
- St. Anne's Hospital
Additional resources:
- Video: What is Teach-Back? (Institute for Healthcare Improvement)
Implement a time-out at discharge
A time-out allows for protected time for the care team and patient/family members during discussion of discharge instructions.

Case study:
- St. Anne's Hospital

4. Identify patients who may have social or medical needs that impede their ability to access follow-up care. 4 strategies to use:

Use tools that help identify high-need patients
Utilize screening tools to identify patients with special needs and coordinate with care managers to address needs prior to discharge.

Case study:
- Beth Israel Deaconess Hospital - Milton
Use digital platforms to gather information
Use digital platforms (e.g., Collective Medical, Patient Ping) to help gather information about patients who have been previously screened as having special medical or social needs.

Case study:
- Addison Gilbert Hospital and Beverly Hospital
Additional resources:
- PreManage ED (Collective Medical)
Use specialized team members to help
Use specialized team members (e.g., community health workers, care coordinators, community paramedics, navigators) or systems (e.g. mobile integrated healthcare) to help with screening and discharge planning for high-need patients.

Case studies:
Develop and periodically update special discharge strategies
Case study:
- Holyoke Medical Center

5. Conduct outreach to patients who have been discharged recently. Here are 2 strategies:

Call or text patients
Place a telephone call or text message to all recently discharged patients to screen for concerns.

Case study:
- Massachusetts General Hospital
- Sturdy Memorial Hospital
Additional resources:
- How To Conduct a Postdischarge Followup Phone Call (AHRQ)
- How To Deliver the Re-Engineered Discharge at Your Hospital (Boston University)
Use home visits or mobile integrated healthcare
Use post-discharge home visits or mobile integrated healthcare to provide follow-up to special populations.

Case studies:
Additional resources:
- Mobile Integrated Health (Commonwealth Care Alliance)

6. Follow-up on test results that are pending at discharge.

Develop a process to follow-up on test results that are pending at discharge (e.g. follow up nurses) to ensure they are reviewed and communicated to the patient. Utilize electronic tools to set up prompts, and include a list of pending test results in discharge notes for follow-up.

7. Use digital tools to document information.

Use digital tools
Digital tools can help ensure that information about the patient’s ED visit is documented in a timely way and available for the provider who will follow-up.

Additional resources:
- PreManage ED (Collective Medical)

Care Coordination and Safe Discharge

Care coordination is essential for patients, but often difficult to manage given the time needed to provide effective discharge instructions