During one academic year, 90 medical students were enrolled in the Medicine Clerkship and submitted their assignments. They each chose one patient they cared for in the hospital and identified barriers to hospital discharge, carried out a post-discharge phone call, and reflected on ways to improve their own future practice to address issues related to transitions of care.
Barriers to Timely or Safe Hospital Discharge
During the chosen patients’ hospitalizations, medical students identified 201 different barriers to timely or safe hospital discharge. Only in three patients were no barriers present, according to students, and one student did not address this question. These barriers were grouped into patient-inherent factors (34.8%), issues related to the patient’s social support structures (25.4%), medication or treatment-related issues (15.9%), problems arranging follow-up (14.4%) and delays in the coordination of care (9.5%).
The most common patient-inherent factor identified was patient noncompliance. A student wrote:
She admitted that having to take medications at multiple times throughout the day was difficult, and she would get confused easily. During her hospitalization and for her discharge, we modified home medications for HTN by adding new medications, discontinuing medications, and changing the dosing of some home medications. During the hospitalization, we increased her doses of amlodipine and valsartan. We emphasized that this information would be outlined clearly in the patient's discharge note. However, the patient was worried that she would get confused about the medications. To simplify the medication administration, we decided to have her throw out all her old medications and only use the newly prescribed pills. Furthermore, for each HTN medication, they would be given once daily with one pill to simplify the process.
In this instance, a patient’s inability to adhere to a complex medication regimen necessitated choice of once daily medications as well as the team discarding old medications to ensure that the patient would not be confused with the changes.
Additional discharge impediments included poor functional status and cognitive impairment (26), health literacy and language barriers (11), psychiatric history or alcohol/drug use (12) and the patient’s anxiety about being discharged (4).
A lack of adequate social support or issues with navigating the health care system featured prominently as barriers to timely discharge in 51 instances. A student described:
On the day of her discharge, the patient let me know that she could not find her food stamps. I got in touch with the social worker who was fortunately able to arrange for God’s Love We Deliver to bring her meals until she got her next batch of food stamps.
Subacute rehab facilities are able to administer IV medications as q8H, but the facility delayed accepting the patient to evaluate the cost of meropenem. Had the facility rejected the patient, the care team would have had to find an alternative place, switch to a cheaper medication (which would have been difficult given the patient’s allergies) or arrange for home care (which would have been complicated by the patient’s lack of social support).
A lack of access to medications or treatment, including the need for prior authorization, the need for optimization of the medication regimen or intolerance led to delays in discharge 32 times. A student noted:
The patient’s CPAP machine had been malfunctioning for weeks and contributed to her admission. I spoke with the social worker who said she would make sure a respiratory therapist visits the patient’s home prior to discharge to ensure that her machine is functioning; however, it turns out there was some delay and that it could not happen until the day after discharge. I was concerned that there would be another delay and that the patient would be stuck with a malfunctioning machine.
Post-Discharge Events and Issues
Eighty-nine (89) students successfully reached their patients by telephone and conducted a post-discharge phone call and inquired about their understanding of their discharge diagnosis, and any issues with medications or follow-up. No issues were identified in only 19 (21.3%) of patients. Six students did not inquire about their patient’s understanding of their diagnosis, but 27 of 83 patients (32.5%) were unable to demonstrate full comprehension of the reason for their recent hospitalization. Over half (46/89, 51.7%) of patients had issues related to medications or treatments prescribed and nearly half (44/89, 49.4%) had problems with the follow-up arranged prior to discharge.
In some patients, cognitive impairment or a language barrier contributed to a lack of understanding of their diagnosis. However, in one patient, a student noted:
The entire team talked with Ms. X daily about her medical condition and why she was in the hospital. However, on the phone, she was unclear about why she remained in the hospital. She did say, “Well I was there because I needed oxygen.” When asked about her discharge diagnosis, she did not know.
The post-discharge phone call revealed that problems with medications were common among patients (18, 20%). Students noted that patients were “unable to tell me the reasons why he was taking the medications he was prescribed” or “could not exactly recall the changes made to her metoprolol dose” or “noted that two of them were for the heart but could not describe why she had been prescribed colchicine.” Upon discharge, several patients encountered difficulties obtaining their medications or treatments. Two comments included:
She told me they could not increase her home oxygen from 4 liters (L) to 6 L when walking because apparently 4 L was the maximum. I did not realize this and should have touched base with the social worker earlier.
She could not afford the fourth medication (esomeprazole) as the pharmacy wanted to charge her $300. She found an over-the-counter version that cost $50, but still was still too much, since she did not have insurance coverage.
An additional 11 instances of medication noncompliance, 8 issues with side effects and 4 errors in taking medications were identified during the call.
Nearly half of the patients encountered problems with post-discharge follow-up. Some either never made (6), forgot (6) or changed (4) the appointment. Several simply did not go (7), lacked transportation (8), had no primary care physician (3) or were confused why they had been scheduled to see a particular physician (2). During the phone call, a few students identified inadequate home care services in several (6) patients.
Another issue was with his home care services, who only came once over the course of 10 days. They were supposed to do wound dressing changes three to four times per week.
A couple of students learned about unforeseen readmission or emergency room (ER) visits.
When I called to check on him on Wednesday evening, he informed me that he had fallen at home on Tuesday morning and had to come to the ER again. He was found to have a humeral fracture and was discharged from the ER to follow up with orthopedics next week for surgery.
Several students learned during the phone call that their patients’ condition improved (21), was persistent (11) or that new problems arose (6).
I decided to call Mr. C's home health nurse to get her perspective on the patient's condition and his understanding of his condition. She told me that Mr. C's leg swelling has worsened since he left the hospital, which she attributes to his prednisone.
The patient actually came back to the hospital the next day because he felt a sensation in his throat that worried him.
Future Practice Improvement
Finally, we asked students to reflect upon their experiences with their patients’ transition and offer some ways by which their future practice will be changed by their new insights into systems-based care. Enhanced communication with the patient and their family and providing more patient education, constituted 92 of these improvements.
“I will try to stop by before the patient officially leaves the hospital to clarify any last-minute questions about diagnoses, management, etc. even after the nurse has walked through the discharge summary with the patient.”
One useful practice is to review the patient’s medication list completely, with one consolidated list. Patients can quickly become overwhelmed and confused when medications are discussed individually, at disparate times, so repetitively reviewing their medications in total is likely a beneficial exercise.
From now on, I will use any opportunity to walk with my patients. I learned a lot more about Mr. M and his challenges during a short walk around the unit. At some point, he had become defensive with the medical team and when we walked, I was not playing the role of a ‘medical professional.’
Greater awareness of the inner workings of the health care system and paying greater attention to psychosocial and sociocultural factors were the focus of 40 practice-based improvements.
I will see if a patient can afford their medications prior to discharge.
One thing I can incorporate into my practice is making sure that patients have adequate transportation to follow-up appointments and that they will be able to cover the cost of planned visits and treatments.
I will make sure to communicate with social work early and often to ensure no patient needs slip through the cracks.
Another area of practice intervention identified by students involved greater collaboration among health care practitioners, including enhanced communication through the medical records.
Although discharge summaries may be short and succinct, be sure to summarize all work and interventions cogently to make all events of the hospital course intelligible to all subsequent medical providers.
“Always touch base with other team members, particularly physical/occupational therapy and social work) about safe discharge planning, even when the patient is medically stable.”
“The transition coordinator had taken care of faxing the discharge summary to various providers. The nurse gave the patient the prescriptions she would need and re-explained the instructions for taking her medications. The social worker had arranged for home PT and visiting nurse services to begin after discharge. Each of these decisions and conversations were necessary to facilitate a safe transition for this patient.”
In a final analysis, we examined the student assignments and asked whether knowledge gained by students reflected an understanding of systems-based practice. The Alliance of Academic Internal Medicine has previously mapped 21 milestones at both undergraduate and graduate medical education to systems-based practice, which can be broadly categorized into learners effectively working in various health care systems (SBP A1-A3), effectively working with members of health-care personnel (SBP-B1-B4), system errors and improvement (SBP C1-C6), health care costs (SBP D1-D4) and cost-effectiveness (SBP E1-E4). We found that excerpts from student assignments could be mapped to 13 of these milestones (Supplemental Table 1).