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

1. Review new and changed medications prior to discharge

Make medication review part of the discharge process

2. Develop a standardized discharge process

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

Develop a standardized discharge form: Use a standardized discharge form for patients who are headed home.

3. Ensure that patients and their caregivers receive effective education

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.

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.

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

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.

Use digital platforms to gather information: Use digital platforms (e.g., PointClickCare, Patient Ping) to help gather information about patients who have been previously screened as having special medical or social needs.

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.

Develop and periodically update special discharge strategies

5. Conduct outreach to patients who have been discharged recently

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

​Use home visits or mobile integrated health care: Use post-discharge home visits or mobile integrated health care to provide follow-up to special populations.

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

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.