Tim Gieseke, MD, CMD

If my elderly mother were discharged home from the acute hospital, she would have been seen by her physician on the day of discharge, and would have had a well-defined discharge summary executed based on a robust, evidence-based Care Transition literature. This discharge summary would be dictated (legible) on the day of discharge and would be comprehensive with documentation of Medication Reconciliation and a detailed "Handoff" care plan. 

If my elderly mother were too sick and disabled to be discharged home, she would be transferred for post acute rehabilitation. Now she would experience a very different discharge process based on tradition and not best practice.  Typically in my community, upon discharge from a postacute stay in a SNF, she would not be seen by her attending, and formal medication reconciliation would not be done.  The physician generally receives a fax requesting discharge home on current medicines with suggested DME and Home Health services. Medical records will then mail a request for a written d/c summary (facility defines the content elements), which is to be completed by memory off-site within one month of discharge.

Is this the kind of "Handoff" I would want for my frail elderly mother, whose physician no longer does post acute care, yet will resume caring for her 1 week post SNF discharge?

I hope your answer would also be "No!" and that we can and should have better "Handoffs. In my facilities, I have encouraged a discharge process that gives attending physicians notification of pending discharges at least 48 hrs prior to discharge so that a discharge visit can be made at the SNF. CMS permits payment for FTF physician (or NP) discharges done within 4 days of the patients discharge, so there is visit flexibility.

I have attached a facility medication discharge form that permits quick review of all proposed discharge medications so that the attending can quickly decide what needs to be modified, is no longer necessary, or should be restarted.

In addition, I have attached a Discharge Summary Template that facilities may provide for Attending Physicians with legible handwriting that contains the important elements of a comprehensive discharge process, based on what we know from the literature on acute hospital to home discharges. For those who have EHRs, or do voice dictation, I have attached the macro that I use for voice dictation (Dragon Speak).

As we enter the new world of QAPI (Quality Assurance, Performance Improvement) in 2013, improving "Handoffs" could be a worthwhile QAPI project in your facility.

Please click here to view the templates mentioned in this article.