Most hospital discharge processes can be improved, as evidenced by readmission rates that remain too high, which are the result of confusion many patients and families face after leaving the hospital. Three relatively simple ideas can reshape the hospital discharge process and increase the likelihood of successful transitions of care: first, begin discharge planning on admission, so that patients and teams are prepared and thinking about the transition; second, use a “home first” approach, so that the default path from the hospital is home; finally, use data to determine the best path of care for the patient. Each of these three approaches can strengthen the discharge planning process and reduce the risk of readmissions, and work even better when combined.

My first experience with thinking about how “discharge begins on admission” was when I was an internal medicine resident providing care for patients at a local VA hospital for veterans from all over New England. If the patient missed the shuttle back to their local medical center, they could be stuck in our hospital for several extra days. Although transportation back to distant medical centers is not an issue for most patients, the concept that we should be thinking about discharge from the day of admission makes a lot of sense. A recent study found that patients, families and hospital staff often feel that transitions in care are often rushed, leading to medication errors and other problems.[1]  Although hospital courses can be unpredictable, most patients are hospitalized for several days, and then discharged home, with some requiring facility-based, post-acute care (PAC) in a Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), or Long-Term Care Hospital (LTCH). If the patient needs home health services or facility-based rehabilitation, waiting until the day of discharge, or even the day before discharge, may make it more difficult for the patient to access the care they need from a home health agency or PAC facility, since there may be limited numbers of agencies or SNF beds in a region. Being proactive and identifying rehabilitation needs early in the hospital stay, and discussing it with the patient and family so they can plan and prepare, can reduce the risks of a poorly-planned discharge that leads to readmission.

It is also critical that the default path for the patient leaving the hospital is home first. A study by MedPAC, the committee that advises Congress on the Medicare program, found that almost 75% of the variability in the cost of an episode of acute care was due to varying uses of PAC facilities and home health in different regions of the country.[2]  In other words, the likelihood a patient received facility-based rehabilitation, and home health, had a lot to do with where they lived rather than their functional status or illness burden. Although the reasons for this are complex, using an approach that relies on home as the default destination can reduce use of PAC facilities, which makes most patients happy, reduces the risk of complications (e.g. falls, infections) from being in the PAC facility, and saves money.

Finally, there are new analytical tools that can help discharge planning teams make better decisions about where patients should go. CareCentrix relies on algorithms using artificial intelligence and machine learning techniques to identify the optimal path of care for a patient by analyzing what happened to similar patients. The tool can determine which PAC facility in the area has done the best job of caring for patients like the one being discharged, and/or which home health agency would be best. It can also calculate readmission risk, which enables patient stratification so that those at the greatest risk of readmission can receive additional support during the transition home. These tools also look at risks beyond readmission – for example, the need for nutritional support for patients facing food insecurity. Although they do not replace clinical judgment, and are continually learning and evolving, the tools are a significant improvement over current practice, which is often to give patients and family a list of facilities/home health agencies and have them choose. A recent study demonstrated that the single piece of information patients and families used when choosing a SNF was its distance from the patient’s home, not quality ratings, or whether there were special programs tailored to meet that patient’s rehabilitation needs.[3]  We can and should do better than that.

Successful hospital discharges depend on early and thoughtful planning, focusing on home as the first choice for discharge, and use of analytics to identify the best provider for a specific patient. It’s time to make these approaches reality.

[1] Gadbois EA, Tyler DA, Shield R, et al. Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility.  J Gen Intern Med. 2018 Oct 18. doi: 10.1007/s11606-018-4695-0. [Epub ahead of print].
[2] Centers for Medicare and Medicaid Services.  Geographic Variation in Standardized Medicare Spending, 2015.  Results of CMS’ readmissions program has hospitals, experts questioning.
[3] Gadbois EA, Tyler DA, Mor V. Selecting a Skilled Nursing Facility for Postacute Care: Individual and Family Perspectives. J Am Geriatr Soc. 2017 Nov;65(11):2459-2465.