5 Ways to Help Close the Gaps from Inpatient to Ambulatory

[Meagan, BSN, RN]

Ever wonder what happens to your patient after they get discharged from the hospital? I'm here to tell you, it can be kind of scary.

As a long time ambulatory CHF clinic nurse, I am sometimes the first health care provider to see a patient after they have been discharged. You can imagine the stories I hear from patients about their hospital stays - both good and bad. It is so important to remember that your patient has a life outside of the hospital walls, and even the smallest effort can have a huge impact on their success once they are gone. I’ve created a list of the top 5 things that bedside nurses can do to close the gaps between hospital discharge and the first ambulatory visit.

1. Good Medication Reconciliation 

I cannot stress the importance of medication reconciliation whenever available. It is so important to know what medications your patient was taking prior to arrival, and in my experience, this is one of the hardest parts of ambulatory patient care. Patients don’t always remember what medications they take and generally have a hard time remembering to bring these medications into the clinic. If you have family available at the bedside, ask them to bring in the patients medications for review. If the patient lives at a nursing facility, review those face-sheets. Involve your pharmacy department if they have this service available.

2. Ask the Basic Questions

Yes you know the patient’s entire medical history, but what do you really know about them as a person? Do you know where they live? Who lives with them? Who will take care of them when they leave? Do they have insurance? Money to afford the new medications the doctor may prescribe? Can they read the discharge instructions you will give them? These are all questions that are imperative for a patient to be successful once they get discharged. You can imagine how many times a patient has told me, “No-one in the hospital asked.” These questions could mean the difference in a successful discharge or a patient’s readmission.

3. Discharge Instructions 

I know, I know…Those pesky 50 page packets you hand out 5 times a day that you think no one reads. But in some cases, they do! Think of those discharge instructions as a patient’s guide back to health. Each line on those papers needs to teach someone who (usually) doesn’t know anything about healthcare. Imagine you were stranded with a flat tire and the only booklet you had titled, “how to change a tire” was blank! How frustrating would that be? Your patient is thinking the same thing. Take the time to really go over the instructions and ensure that what they need to know is really there. If there needs to be a follow up – has it been scheduled? If there is a medication change – is there instructions for how to take it? These are simple questions your patient won’t know the answer to without reading those instructions, so be sure they are clear and easy to follow.

4. Family Teaching

If you’ve asked those basic questions, chances are you know who will be helping out your patient when they get back home. Those are your people. Your new best friends if you will. Make sure they understand (if the patient is comfortable with it of course) what is going on and how much support your patient might need once they are discharged. If there are new medications – teach them. If there is a new diet – teach them. If there is a wound vac – teach them. Your patient might be overwhelmed and rely on this teaching once they go home.

5. Ensuring Prescriptions are Filled

Remember when I said I cannot stress the importance of medication reconciliation? We’re coming full circle here. Prescriptions! If a good medication reconciliation was completed on admission, there’s a good chance you can tell if your patient will be sent home on anything new. Without a new prescription from the doctor, the patient could make it home and never start this new medication. Checking your discharge instructions against the new prescriptions will tell you if the doctor sent it in. Make sure your patient doesn’t leave without it!

On a good day, these tasks can seem daunting, but keep in mind what you are doing it for – the patient. In the end, the patient will be grateful, and you will know you contributed to their success.

What are some other ways you have utilized to ensure a smooth transition?

[Wuzzie]

This is where having an excellent case manager comes in. In my facility all in-patient floors have at least one but usually multiple case managers whose job it is to ensure that the patient gets the right care and follow up after discharge. They collaborate with the providers to make sure appropriate orders are in and schedule appointments prior to the patient being discharged. This significantly decreases bounce back admissions and complications. It also allows for the bedside nurse to hit the most important things when reviewing discharge plans resulting in fewer miscommunications. The discharge plan is documented in a template format that is easy to review and can be printed.

The flip side of this is when the case manager is less than optimal bad things can and do happen.

[Meagan, BSN, RN]

On 11/7/2019 at 8:28 AM, Wuzzie said:

This is where having an excellent case manager comes in. In my facility all in-patient floors have at least one but usually multiple case managers whose job it is to ensure that the patient gets the right care and follow up after discharge. They collaborate with the providers to make sure appropriate orders are in and schedule appointments prior to the patient being discharged. This significantly decreases bounce back admissions and complications. It also allows for the bedside nurse to hit the most important things when reviewing discharge plans resulting in fewer miscommunications. The discharge plan is documented in a template format that is easy to review and can be printed.

The flip side of this is when the case manager is less than optimal bad things can and do happen.

Thank you for your response! We have a wonderful case management team in the facility I work in, but I do think they have to share the units and that can be so time consuming. Although discharging a patient is definitely a team effort, in my experience, the bedside nurse is the last person the patient contacts when leaving the facility. It is so important that the information we give them on discharge is accurate, as I like to compare the discharge instructions with GPS. If we give them the wrong directions, they'll end up at the wrong place!