Description

Providing safe transitions between healthcare settings is a core focus in palliative medicine. In the development of a new inpatient palliative consult service we have seen where the hospital’s existing discharge process, though usually adequate for regular home discharges, has failed to provide an appropriate transition to the home hospice setting.

Our team has developed a system to supplement the current discharge process without adding responsibilities to our already overburdened nurses. Our supplemental discharge system highlights enhanced communication and a written discharge checklist to be completed by a family member of the patient before leaving the hospital. Our consult team provides enhanced communication with the patient and families by giving access to the team’s 24/7 pager and assigning a family member to complete the checklist on day of discharge after discussing each item on the checklist and its importance. We also contact the accepting hospice agency to discuss each patient, ensure continuity, and reinforce team availability. We plan to evaluate the success of the supplemental system with follow-up calls to families and hospice nurses post-discharge. Roles and duties for team members will be discussed. Feedback, discharge complications (re-hospitalization, uncontrolled symptoms, lost follow-up), and modifications to our protocol will be reported.