Hospital discharge planning hinges on good communication
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Question: My brother was in a bad car accident and was taken to a trauma centre at a major hospital. He was improving and we really liked the care he was getting. But he was then sent to another hospital for the rest of his recovery. While the new hospital was closer to home, the move seemed very disruptive. Why couldn’t he just stay in one place? And is there anything we could have done to make sure he got the best care?
Answer: It is now fairly common for patients to be moved to different facilities – particularly if they need highly specialized care. You’ll find that certain hospitals act as regional hubs for treating specific conditions, such as trauma injuries, severe burns, strokes, heart disease or cancer.
“It requires well trained people, plus a lot of infrastructure, to deliver this care,” says Dr. Andy Smith, Executive Vice-President and Chief Medical Executive of Sunnybrook Health Sciences Centre.
“So, it makes sense to have just a few centres providing these services where they can be done really, really well.”
Indeed, numerous studies have found that patients, who need complicated procedures tend to do better when they are treated by people with a great deal of experience. Practice makes perfect, so to speak.
Smith points to the example of surgery for pancreatic cancer. A few decades ago, it was routinely done at numerous hospitals throughout Ontario – and a patient’s risk of dying from the operation was as high as 10 percent. Now, the procedure is performed at only a limited number of hospitals in the province and the mortality rate from the operation has dropped to less than two percent. “That’s a really big improvement,” Smith says.
The development of specialized centres for doing certain procedures has resulted in more and more patients being moved from one health care institution to another. Patients are often admitted to one hospital to receive a particular type of care and, as their condition improves and they no longer need specialized treatment, they are transferred to another facility to continue their recovery. That other facility might be a rehabilitation centre, a long-term care home or a community hospital closer to where the patient lives.
Without these transfers, the specialized centres would be severely restricted in the number of patients they can serve. “Getting the person closer to home opens up the bed for the next patient,” Smith explains. What’s more, as the medical condition of patients’ change, their needs may be better met at another type of facility.
Still, bottlenecks can develop in the system, inhibiting the easy transfer of patients. Many health care facilities are operating close to – or even above – capacity. This means it can sometimes be hard to find spots for patients.
Maybe it’s not surprising that Christine Elliott, who heads up Ontario’s relatively new office of the Patient Ombudsman, hears many complaints arising from these transfers, or when patients are sent home. In fact, “inappropriate or poorly-planned discharges from hospital” are among the top five issues being monitored by her office.
“We all know our health care system is under stress right now with long wait times and overcrowding, but that shouldn’t take away from the importance of looking at each patient as a person with wishes and feelings and concerns, not just as a number,” Elliott said in an interview.
Since her provincially-funded office opened on July 1, 2016, it has received approximately 1,500 individual complaints from patients and caregivers. Problems relating to “communication or perceived lack of communication” are linked to about 60 percent of those complaints.
“People often feel that they haven’t been given the information and time needed to make fully informed decisions, and they feel pressured to make a decision before they are ready,” according to a statement released by Elliott’s office.
Smith agrees that more can be done to improve communication – especially as it relates to hospital discharges. “I firmly believe that we need to have timely, high-quality communications about the transitions,” he says.
Many hospitals are trying to address these issues by starting conversions about discharge soon after a patient is admitted to the facility. But there is no standardized process – at least not yet.
“From what we have seen, it does seem to vary from hospital to hospital,” Elliott says. “Some hospitals have very good systems with very good communication, and others are still struggling with the best way to communicate effectively with patients and families about their options for when it comes time to leave the hospital.”
So, what can patients and their caregivers do to improve the chances of a smooth transition? Here are some tips:
- Start the conversation “as early as possible” so there is enough time to make informed decisions, Elliott advises.
- Families should ask their hospitalized loved ones about their preferences for their care, and those wishes should be conveyed to health care staff.
- Ask if there are fees or charges associated with any aspect of the patient’s continuing care.
- Options for patients should be put in writing. “That’s important because very often, when people are under stress and not feeling well, they can forget things,” Elliott says.
- A discharge summary accompanies each patient to the next health care facility. Patients may request a copy of that report, which provides details of their medical condition, Smith says.
- If the patient is going to be transferred to another health care centre, the family may visit the facility beforehand to check it out. The patient’s health care team should also have information about specific programs at the other facility.
- Ask about the services provided by the Ontario Telemedicine Network (OTN), Elliott says. Patients in remote areas can see medical specialists through OTN’s video-conferencing without travelling long distances to a major medical centre.
- OTN can also assist with home care by remotely connecting patients to support workers through electronic devices such as tablets.
- The family doctor, who might be playing a key role in the patient’s overall recovery, should be kept informed about the hospitalization.
- When patients are being sent home, families should make sure they know whom to contact if there is a setback in the person’s condition.
If the patient or family is displeased with the care or discharge process, it’s important to know that all hospitals have a special office that deals with such concerns. At Sunnybrook, it’s called the Office of the Patient Experience. At other institutions, it might be known as the Patient Relations Office.
Regardless of the name, it performs a similar role at each hospital. The office acts as a mediator between patients or their family members and front-line health care staff.
You must go through this process before you can take a complaint to Ontario’s Patient Ombudsman. “We are basically an office of last resort,” Elliott says, adding that complaints are usually resolved more quickly when addressed at the local level by those directly involved in the patient’s care.
“I can’t state enough how important basic communication is, and how often it gets overlooked in these circumstances,” she says.
Smith agrees. “Good communication should start right from the beginning when the patient is admitted to hospital.”