Going home with a clear next step

What we found in the news

In a June 6, 2023 memorandum (opens in a new tab), the Centers for Medicare & Medicaid Services highlighted missing or inaccurate information when people move from hospital to post-acute providers, including home health agencies. Its concerns included information about preferences and the circumstances in which support would happen.

That reminder sits alongside an established resource: AHRQ’s IDEAL discharge planning guidance (opens in a new tab), originally published in June 2013. One of its directions is:

“Listen to and honor the patient and family’s goals, preferences, observations, and concerns.”

— AHRQ, Strategy 4: Care Transitions From Hospital to Home

The memo is a reminder about discharge requirements; IDEAL is practical guidance. Neither is a new study showing that the suggestions below produce a particular outcome. Together, they prompt a useful question: how does a discharge plan become something people can use when they get home?

Why this matters to us

Picture an illustrative conversation before someone leaves hospital. The person wants to sleep in their own bed. Their daughter can collect them, but cannot stay overnight. A follow-up visit has been suggested, although neither knows who is arranging it.

Everyone may agree that home is the destination while holding a different picture of the first day there.

Our genus perspective is that the ordinary details deserve a place in the conversation. The person going home can explain what matters to them. A supporter can say what they can realistically offer. Professionals bring the clinical judgment and service knowledge needed to work through unresolved questions. Each contribution helps reveal what the plan is asking people to do.

Walk through the next step together

For discharge and community teams, a useful discussion starts with what happens after the person leaves the building.

An appointment on a list may still need a booking, a telephone call or transport. A visiting service may have been requested without a first visit being confirmed. Ask who is taking each remaining action and how the person will hear that it is arranged. Record an unresolved arrangement plainly so it can be followed up.

Consider the practical route to the next step. Can the person reach the contact number? Will they need an interpreter, a paper copy or help using an online service? Is the available supporter actually free at the expected time? These questions invite the team to adapt the arrangement instead of expecting the person to make an unsuitable arrangement work.

Give the person time to explain the plan in their own words, using whatever communication support they need. Treat a different understanding as a reason to explain or reconsider something. A reassuring nod at the end of a busy conversation may leave questions undiscovered.

Clinical instructions need to come from the responsible care team. The purpose of these questions is to make the agreed arrangements understandable and workable, not to create another set of treatment instructions.

Make it possible to ask again

A question may become clear only after someone is home. A contact name is most useful when people also know which questions that person can address, when the service is available and what the team has advised if the usual contact cannot be reached.

A family member should not have to infer that being listed as a contact means taking responsibility for every next step. Confirm what they have agreed to do. When an arrangement depends on support that is unavailable, bring that gap back to the responsible team.

For organizations, there is also something to learn from the questions that return. If people repeatedly ask where to find a visit time, look at how that information is explained and shared. Ask whether the change made it easier to find. That is a practical improvement question, not evidence that any single communication tool has solved the transition.

The genus connection

Today, the genus Discharge Companion approach (opens in a new tab) describes a configured experience where people can return to prepared discharge resources and teams can use available coordination tools for follow-up.

A program might make its reviewed information easier to revisit through the Care App or Care Wall. The audience, access, content and staff workflow need to be agreed for that program. The organization remains responsible for the clinical instructions and response arrangements; the presence of a digital resource does not establish that another service has accepted a referral or that a visit is booked.

For us, the useful role of technology is to support the conversation and help its agreed details remain available afterward.

One question to take away

Before someone goes home, can they—and the people involved—describe the next step in the same practical terms?