International Journal of Health Care Quality Assurance

Barriers to discharge from inpatient rehabilitation: a teamwork approach

Lisanne Catherine Cruz, Jeffrey S. Fine, Subhadra Nori,
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Lisanne Catherine Cruz, Jeffrey S. Fine, Subhadra Nori, (2017) "Barriers to discharge from inpatient
rehabilitation: a teamwork approach", International Journal of Health Care Quality Assurance, Vol. 30
Issue: 2, pp.137-147, https://doi.org/10.1108/IJHCQA-07-2016-0102
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Discharge
Barriers to discharge from from inpatient
inpatient rehabilitation: rehabilitation

a teamwork approach
Lisanne Catherine Cruz, Jeffrey S. Fine and Subhadra Nori 137
Rehabilitation Medicine, Elmhurst Hospital Center, Elmhurst, New York, USA
Received 17 July 2016
Revised 9 August 2016
Accepted 30 August 2016
Abstract
Purpose – In order to prevent adverse events during the discharge process, coordinating appropriate
community resources, medication reconciliation, and patient education needs to be implemented before the patient
leaves the hospital. This coordination requires communication and effective teamwork amongst staff members.
In order to address these concerns, the purpose of this paper is to incorporate the TeamSTEPPS principles to
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develop a discharge plan that would best meet the needs of the patients as they return to the community.
Design/methodology/approach – Through a gap analysis, barriers to discharge were identified from the
following disciplines: nursing, social work, physical and occupational therapy, psychology, and rehabilitation
physician. To improve communication, weekly meetings and twice-weekly huddles were implemented so that
concerns regarding discharge obstacles could be identified and resolved. Visibility of discharge dates were
improved by use of graduation certificates in patient rooms and green ribbons on patient wheelchairs.
Findings – After implementation of this discharge intervention, length of stay was reduced providing cost
savings to the hospital, patient satisfaction on HCAHP surveys improved and demonstrated patient
satisfaction with the discharge process, and readmission rates improved.
Originality/value – This study demonstrated that effective teamwork and communication can improve
patient safety and satisfaction during the discharge period.
Keywords Leadership, Patient safety, Health and safety, Patient satisfaction,
Continuous quality improvement, Discharge barriers, Length of stay
Paper type Research paper

Background
Ensuring patient safety and improved health throughout the hospital course has now
extended itself to the discharge process. Great care goes into helping patients’ well-being
while hospitalized and the same care needs to be taken to ensure patients transition home
safely. Safe and efficient discharges are becoming increasingly important considering the
trend toward shorter hospital stays and more care in the community (Mistiaen et al., 2000).
Despite the growing concern for discharge safety, research demonstrates that a variety of
adverse events frequently occur (Mistiaen et al., 2000). Studies suggest that 45 percent of
patients over the age of 65 have medication errors ( Jencks et al., 2009). Additionally,
18 percent of Medicare patients are readmitted within 30-days (Medicare & Medicaid
Statistical Supplement, 2007), suggesting they were discharged too soon or did not have the
appropriate information and follow-up once they left the hospital. Poor discharge planning
contributes to unsafe return to community, prolonged length of stay (LOS), and ultimately
decreases patient satisfaction and wellbeing. Conversely, improved discharge planning may
promote recovery, sustain patient’s wellbeing after re-entry into the community, decrease
readmissions, and improve the financial climate of the healthcare system. The resolution
may be development of a comprehensive discharge planning system.
A systematic review from 21 randomized control trials involving over 7,000 patients
showed that a well organized discharge plan adapted to each patient results in a reduction in International Journal of Health
Care Quality Assurance
Vol. 30 No. 2, 2017
Disclosures: the authors report no conflicts of interest. They did not receive any financial support or pp. 137-147
benefits for the work. Data and results presented in this paper have not been published or submitted © Emerald Publishing Limited
0952-6862
for publication elsewhere. DOI 10.1108/IJHCQA-07-2016-0102
 IJHCQA hospital LOS and readmission rates for older people (Shepperd et al., 2009). Several studies have
30,2 identified the context in which the discharge planning process is either inhibited or promoted.
One such study, conducted by an interdisciplinary group at a UK Hospital, used a qualitative
design to investigate how teamwork influenced discharge planning (Pethybridge, 2004). The
authors concluded that teamwork was inadequate when leadership was limited and there was
uncertainty about task delegation, causing duplication, service gaps and time delays in
138 discharge planning. Similarly, Wong and colleagues (2011) examined the perspective of
frontline healthcare professionals and determined that a structured hospital-wide discharge
policy was needed to ensure that appropriate discharge planning was feasible. Additionally,
they outlined that a lack of communication, a lack of clearly identified roles among providers,
and minimal multidisciplinary collaboration as potential barriers to effective discharge
planning. Lastly, the authors recommended that a barriers checklist be utilized to ensure
everything was done before the patient left the hospital.
As evidenced by these studies, teamwork, communication, good leadership and clear
identification of roles among medical staff have been posited as key factors in enhancing
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quality and safety in discharge planning. One evidence-based tool aimed at optimizing
patient outcomes by improving communication and teamwork skills among clinical,
administrative and support staff is Team Strategies and Tools to Enhance Performance and
Patient Safety or TeamSTEPPS (Agency for Healthcare Research and Quality, 2006).
This system is comprised of teachable and learnable skills including leadership, situation
monitoring, mutual support and communication (please see Figure 1).
This study sought out to address the issue of poor discharge planning, specifically targeting
teamwork and communication, using the TeamSTEPPS approach. This study was conducted in
an Inpatient Rehabilitation Facility (IRF) in a large metropolitan, Level 1 Trauma Center. As
mandated by the Centers for Medicare and Medicaid Services, patients in an inpatient
rehabilitation unit must participate in three-hours per day, at east five-days per week of therapy in
some combination of physical therapy, occupational therapy, speech therapy, neuropsychological
therapy and recreational therapy (Centers for Medicare and Medicaid, 2015a). Additionally, at
least 60 percent of the facility’s total inpatient population must require IRF treatment for one or
more of 13 conditions; stroke, spinal cord injury, congenital deformity, amputation, major multiple
trauma, fracture of the hip/femur, brain injury, neurological disorders (multiple sclerosis,
parkinson’s disease, motor neuron disease, etc), burns, active polyarticular rheumatoid arthritis,
psoriatic or seronegative arthropathies with functional impairment, systemic vasculidities with
joint inflammation resulting in significant functional impairment, severe osteoarthritis involving

TeamSTEPPS-Framework
Key Principles

• Strategies Team Structure

Delineates fundamentals such as team size, leadership,
composition, identification, and distribution
and
Leadership
• Tools Ability to coordinate the activities of team members by
ensuring team actions are understood, changes in
to information are shared, and that team members have
the necessary resources
• Enhance Situation Monitoring
Process of activity scanning and assessing situational
elements to gain information, understanding, or
• Performance maintain awareness to support functioning of the team

and Mutual Support

Ability to anticipate and support other team members’
needs through accurate knowledge about their
Figure 1. • Patient responsibilities and workload

TeamSTEPPS • Safety Communication

Process by which information is clearly and accurately
framework exchanged among team members
 two or more weight bearing joints, and joint replacement (either bilateral joint replacements, Discharge
BMI W50, or over the age of 85) (Centers for Medicare and Medicaid, 2015b). In total, 80-90 from inpatient
percent of the inpatient population in this study’s IRF is made up of these diagnoses with an over rehabilitation
representation of patients with stroke, TBI, SCI and polytrauma since the unit is a part of a larger
Trauma Center. As such, these patients require extensive nursing care, in addition to the three
hours per day of therapy.
The IRF utilized in this study also serves an economically diverse population who are 139
frequently undocumented and undomiciled. This creates further challenges to a safe transition
home because in addition to a sudden life changing event such as a stroke or brain injury, these
patients also have minimal financial support to assist with homecare, medications, and medical
equipment. As a result, planning a safe discharge at this IRF is uniquely difficult. In order to
address the inherent obstacles to discharge planning, the authors incorporated the TeamSTEPPS
principles to develop a discharge plan that best meet the unique needs of the patients.

Methods
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Subjects included all patients admitted to the community-based IRF utilized in this study.
There were no inclusion or exclusion criteria as the implemented discharge protocol became
standard of care on the unit starting in July of 2014. Patient data were not used for research
purposes and all outcome measures were taken from publically accessible data. As such, the
Institutional Review Board determined that approval was not necessary.

Interventions
Gap analysis – identifying barriers to discharge. Potential disposition obstacles were
identified using the A3 Problem Solving methodology in order to evaluate gaps in
communication and challenges faced in discharging a patient in a timely and safe manner
(Sobek and Smalley, 2008). The A3 Process helps people engage in collaborative, in-depth
problem-solving. It drives problem-solvers to address the root causes of problems which
surface in day-to-day work routines. Through small focus groups, all team members took
part in the A3 method using the format outlined in Figure 2.

Date: Latest Draft Owner: Preparer of the A3

Approval Date: Manager Approval:

PROPOSAL
• Your proposed countermeasures
BACKGROUND
• Why are you talking about it?
• What is the business case? What business problem are you trying to solve or analyze? Be
very concise – communicate WHY you are addressing this issue

PLAN
• Timeline with who, what, when, where, how

CURRENT CONDITIONS
• What is going on?
• Use facts, data
• Be visual – use Pareto charts, pie charts, sketches
• Make the problem clear

GOAL
• State the specific target(s). State in measurable or identifiable terms

ANALYSIS FOLLOW UP Figure 2.

• Use the simplest problem-analysis tool that will suffice to find the root cause of the problem:
five whys; fishbone diagram, problem or process analysis tree, 7 QC tools (old or new), tools
• What issues or remaining problems can you anticipate? A3 problem
from the Six Sigma, Kepner-Tragoe, Shainen, Taguchi, TRIZ or other toolbox of your choice solving process
 IJHCQA A problem was identified and the team then discussed the current condition and what the
30,2 target condition should be. Subsequently, a root cause analysis was performed for each
identified problem to prevent recurrence. With the root causes in place, countermeasures
were then developed to address each basic cause for the identified problem. A plan on how
these countermeasures will be implemented was developed and carried out. Once the plan
has been implemented, constant follow-up was undertaken in order to ensure that the
140 objectives were met. If results were positive, then an infrastructure to sustain change was
put into effect. From this A3 Process, the “Barriers to Discharge Checklist” was created for
the following disciplines; nursing, social work, physical and occupational therapy,
psychology, and rehabilitation physician (Figure 3). A discharge timeline was initiated so
that discharge planning could occur from the onset of the admission. All team members
were given the checklist at the time of admission and all barriers were reviewed at team
meeting and huddles.
Team meeting. The framework for the TeamSTEPPS approach is based on the principles
of developing a team structure, fostering leadership, improving communication, promoting
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situational awareness and mutual respect (Figure 1) (Agency for Healthcare Research and
Quality, 2014). Using these principles, the IRF in this study implemented a weekly
multidisciplinary team meeting with nursing, social work, physical and occupational
therapy, psychology and rehabilitation physicians, to address the objective of improving the
discharge planning process. This meeting was designed to establish a team structure with
the Rehabilitation Physician as the leader, coordinating the other team members and
ensuring adequate resources to carry out the team objectives. The meeting was scheduled
one to two days after admission and again weekly until the time of discharge. These
meetings served to set an agreed-upon discharge date, identify any challenges to discharge,
and screen for need of a family meeting. Open communication among team members was
encouraged and a representative from each discipline would briefly discuss each patient in
terms of progress, goals met and goals yet to be achieved. Additionally, barriers that needed
to be addressed for the patient to make a safe transition back to the community were
identified. This shed light onto all aspects of the patient’s care and their progress so that
every team member could be on the same page with regards to goals, progress, and the
wellbeing of each patient.
Twice-weekly huddles. Utilizing a fundamental tenant from the TeamSTEPPS model,
“huddles” were incorporated into our intervention. A huddle is an informal or ad hoc planning
session that serves to re-establish situation awareness. Critical issues can be discussed as well
as emergent events. The purpose of the huddle is to reinforce plans already in place and assess
the need to readjust the plan. In order to promote constant communication and re-evaluation
of discharge barriers, these informal team meetings took place twice-weekly. Often a barrier in
one arena of care was not obvious to other providers. These huddles allowed staff to voice
their concerns and for a solution to be defined as a team, thereby promoting situation
awareness. Team leaders were made aware of any emerging conflicts or anticipated problems,
allowing them to constantly monitor the current situation for each patient. This situation
monitoring promoted mutual support as staff members felt like they could utilize these
huddles as a forum for discuss concerns and offer suggestions and ideas with regards to
patient care, discharge preparation or workflow on the unit. Additionally, the huddles
increased accountability for each team member to follow through on their assigned
responsibilities since the entire team was aware of assigned duties.
Visibility of discharge date. As a way of promoting effective communication, the
TeamSTEPPS model focuses on developing a “shared mental model.” This results when each
team member is aware of the same information, plan and problem solve to develop a team plan
of care. To ensure that all team members knew what to expect, the agreed-upon discharge date
 Physician Rehabilitation Psychology
All co-morbid conditions and impairments identified
Discharge
All co-morbid conditions and impairments identified
from inpatient
All team members notified of discharged date Concerns regarding achievement of STG (interim) or LTG
(discharge)
rehabilitation
Inpatient diagnosis work-up, lab work completed
Patient and family education and training completed
Clear treatment plan for medical issues regarding impairments, burden of care

Patient and family education completed regarding medical
conditions
Patient family education completed regarding medications,
self-administration, wound care, home monitoring, burden
of care
Cognitive impairment, diminished competency identified 141
Substance abuse issues addressed
Psychological education including self-concept issued
completed

Cognitive impainnenl, diminished competency identified Depression and or anxiety if present and effectively
managed
Family meeting indicated and completed

Nursing
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Occupational Therapy
All co-morbid conditions and impairments identified
All co-morbid conditions and impairments identified

Clear treatment plans for impairments/disability Clear treatment plan for impairments/disability

Concerns regarding achievement of STG (interim) or LTG Concerns regarding achievement of STG or discharge
(discharge)
Patient and family education completed regarding medical
Patient and family education and training completed condition
regarding impairments, MAE and DME, burden of care
Patient and family education and training completed
Required DME has been ordered and MD signed regarding impairments, MAE and DME, burden of care
prescription list placed in chart
Patient and family education completed regarding
DME Recommendations: mediations, self-administration, wound care, home
( ) Wheelchair ( ) Commode monitoring, burden of care
( ) Raised Toilet Seat w/clamp
Healthcare proxy, guardianship, advanced directives
( ) Shower chair w/back
identified
( ) Toilet Safety Rails ( ) Grab Bars
( ) Transfer Tub Bench ( ) Tub Rail
( ) Hip Kit ( ) Hand held shower
( ) Ambulation Device (PT)
Rehabilitation Clinical Social Work
Physical Therapy
Patient and family notified discharge date
All co-morbid conditions and impairments identified
Newly identified reasons that patient cannot be discharged
Concerns regarding achievement of STG (interim) or LTG
(discharge) to community

Patient and family education and training completed Change in dwelling, loss of family support
regarding impairments, MAE and DME, burden of care
Uninsured patient MAE and DME requirements provided

Required gait aide/wheelchair has been ordered and MD Transportation home established
signed prescription list placed in chart
Outpatient transportation established, information provided

Healthcare proxy, guardianship, advanced directives Figure 3.

identified Barriers to
discharge checklist
Family meeting indicated and completed

for each patient was written on the patient’s dry erase board in their room. This allowed team
members to “get on the same page” and ensured that care was synchronized so that all goals
could be met before the patient returned home. For example, seeing this date would reinforce
the need for insulin administration training or Lovenox injection training well in advance of the
discharge date. Therapists were always clear on when DME orders were needed and
physicians could be sure to schedule appropriate follow-up appointments before the patient
 IJHCQA returned to the community. Additionally, the easily visualized discharge date provided an
30,2 opportunity for the patients and families to verbalize their readiness to return home and voice
any concerns that they may have. These concerns were brought back to the team and
addressed. For example, if the patient did not feel that in a week they would be able to climb
their seven steps to enter their home, this concern would be addressed by PT and sessions
would focus more on stair negotiation. Similarly, family members could arrange to pick the
142 patient up and to have their home ready or the patient’s arrival.
Graduating from IRF. Three- to four-days before discharge, a Rehab Graduation
Certificate is placed in the patient’s room. This served as a positive reinforcement to the
patient that they had been successful in rehab and were progressing to outpatient care. This
enabled the patient to feel confident in their readiness to return home. Also, green ribbons
were placed on the patient’s wheelchair, again providing visibility to all staff members that
this patient would be discharged in the next few days. This was another reminder that all
goals and responsibilities would need to be met within the week.
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Outcome measures
LOS. Clinical Functional Independent Measures data are uploaded to a National Rehabilitation
Outcomes Database via the UDS-MR-PRO ® system (UDS, 2015). This provides benchmarking
and comparative performance reports regarding program improvements, including IRF LOS.
LOS before, during and after the intervention was compared using this tool. Specifically, LOS
data were analyzed from the years 2012-2015.
Hospital consumer assessment of healthcare provider and systems (HCAHPS). HCAHPS is
a standardized survey and data collection methodology for measuring patients’ perspectives
on hospital care (Centers for Medicare & Medicaid Services, 2015b). It includes 21 questions
with regards to patient’s perspectives on care. Nine topics were represented in the questions
including communication with doctors and nurses, discharge information, responsiveness of
hospital staff, pain management, communication about medicines, cleanliness, quietness
and transition of care. The survey also includes four screener questions and seven
demographic items, which are used for adjusting the mix of patients across hospitals and for
analytical purposes. The survey is 32 questions in length. The data are publically available
and does not include any patient identifiers.
Readmission rates. In all, 30-day readmission rates were evaluated using the data
collected from the hospital-wide Quality Management Department. These data included
the number of discharges from this study’s IRF annually from 2012 to 2015. Additionally,
the total number of 30-day readmissions, the rate of all cause 30-day readmissions, and the
rate of same diagnosis 30-day readmissions were obtained. These data are collected and
analyzed by the hospital administration as a mandatory quality measure. This information
is public and does not include any patient identifiers.
Financial status. The average cost per day for a patient in this study’s IRF varies based
on the patient’s impairment group code and the case-mix group (UDS, 2015). That is, fee
scales utilize the diagnosis on admission in addition to factors such as age, LOS,
comorbidities, and severity to determine prospective payment. The expected payment can
be determined using the National Rehabilitation Outcomes Database via the UDS-MR-PRO
® system (UDS, 2015). For a patient meeting the 60 percent rule, payment for the entire
admission varies from $8,000.00 to $50,000.00. The average payment per day in this study’s
IRF was $2,000, based on the data gathered by the Quality Management Department.

Analysis
The focus of this study was to describe the change in LOS, patient satisfaction, discharge
safety and readmission rates after the implementation of our intervention. As such,
 statistical analyses of the results were not attempted given the limited number of study Discharge
participants and survey response rates. Rather, the investigators focused on describing from inpatient
clinical significance when appropriate. rehabilitation
Results
The number of discharges per year from 2012-2015, the average annual LOS, total rate of
readmissions for all diagnoses and the rate of readmissions for the same diagnosis are 143
described in Table I.

LOS
LOS was compared before and after the initiation of this study’s discharge planning
intervention. In 2012, there were 317 discharges from this study’s IRF and the average LOS
was 13.2 days. This was comparable to average LOS at all other regional facilities in 2012,
which was also 13.2 days. In 2013, there were 312 discharged patients and the average LOS
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was 13.0 days at this study’s IRF compared to 13.4 days at other regional facilities. In 2014,
294 patients were discharged from this study’s IRF and the average LOS was 0.9 days
shorter than the regional average; 12.5 days compared to 13.7 days. Lastly, in 2015, there
were 236 discharges from this study’s facility and the average LOS was one day shorter
than the regional average; 12.5 days as compared to 13.5 days (Figure 4). From 2012 to 2015,
the average LOS in this study’s IRF decreased by 0.7 days.
HCAHP data. HCAHP data were compiled from surveys collected during two time
periods: twelve months before the implementation of this discharge protocol from August
2013 to July 2014 and after the role out of this intervention from August 2014 to July 2015.

Total no. of Avg. % all cause 30-day readmit % same diagnosis 30-day readmit
Year discharges LOS rate rate

2012 317 13.2 11 1.26 Table I.

2013 321 13 12.5 2.18 Discharges, length of
2014 294 12.5 11.2 1.02 stay and readmission
2015 236 12.5 19.6 0.42 descriptive statistics

13.8
13.6
13.4
Length of Stay (days)

13.2
13
12.8
12.6
12.4
12.2
12
11.8 Figure 4.
2012 2013 2014 2015 Length of stay at this
study’s IRF vs
Region 13.2 13.4 13.7 13.5 regional LOS from
Our Facility 2012 to 2015
13.2 13 12.5 12.5
 IJHCQA The global HCAHP data showed respondents were more likely to rank the hospital an 8-10/
30,2 10 in the year following the initiation of this intervention (Figure 5). Similarly, respondents
to the HCAP surveys were more likely to recommend the hospital after the start of this
study (Figure 5).
The HCAHP information was broken down further to specifically evaluate patient’s
perceptions of discharge information and care transitions. This section of the HCAHPS
144 survey evaluates perceptions of care transitions and includes three questions; whether the
hospital staff always took preference into account when planning a discharge, whether
the respondents had a good understanding of how to manage their health after discharge, and
whether the respondent understood the purpose of taking their medications. Again, surveys
comparing the 12-months before and after the implementation of the discharge intervention
were utilized. Respondents rated their perceptions of the discharge process more favorably in
the surveys from the 12-months following implementation of the intervention (Table II).
Readmission rates. As outlined in Table I, 30-day readmission rates for all diagnoses
from 2012 to 2015 varied from 12.5 to 10.6 percent. In total, 30-day readmission rates
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decreased from an annual average of 11 percent in 2012 to 10.6 percent in 2015. The rate of
30-day readmissions for the same diagnosis from 2012 to 2015 ranged from 2.18 to 0.42
percent. Specifically, rates decreased from 1.26 percent in 2012 to 0.42 percent in 2015.
Financial savings. The average reimbursement per day for a patient admitted to this study’s
acute IRF is $2,000.00. LOS per patient decreased by 0.7 days from 2012 to 2015 resulting in an
average savings of $330,400.00-$411,600.00 in 2014 and 2015 from early discharge alone.

Discussion
After the implementation of our discharge intervention, LOS decreased, patient satisfaction
improved, discharge information was optimized, readmission rates declined, and the

100
August 2013-July 2014
90
August 2014-July 2015
80

70

60

50

40

30

20

10
Figure 5. 0
HCAHPS global score
Rate the Hospital 10 Recommend the Hospital

Discharge information n August 2013-July 2014 (%) August 2014-July 2015 (%)
Table II.
HCAHPS discharge Staff talked about help when you left 43 71.4 83.7
information Info resymptoms/prob to look for 44 82.1 90.9
 financial wellbeing of the IRF was improved. These findings have been echoed in the Discharge
Cardiac Heart Failure and geriatric literature, demonstrating that a multidisciplinary and from inpatient
comprehensive discharge plan can reduce costs, short-term readmissions rates, and LOS rehabilitation
(Naylor et al., 1999; Anderson et al., 2005).
Decreasing LOS is important for several reasons. First, a shorter hospital stay minimizes
risk of hospital-acquired infections (Magill et al., 2014). Reducing risk of nosocomial infections
decreases patient morbidity, improves functioning and reduces cost to the hospital. Similarly, 145
a decreased LOS is financially beneficial to the IRF as it increases likelihood of insurance
coverage for the duration of the hospitalization and saves potentially lost revenue from
bundle payments. In addition, decreased LOS facilitates faster turnover of beds and increases
the number of new admissions, thereby increasing the potential for new revenue (Anderson
et al., 2005). Securing the financial well-being of this study’s IRF is paramount given the
propensity for large community hospitals to cut rehabilitation beds in lieu of acute care
beds – a trend we see far too often in modern healthcare when hospitals are pressed to empty
emergency rooms. The financial savings from decreasing LOS and minimizing readmission
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rates is pivotal to the survival of IRFs and community hospitals nationwide and globally.
A recent study examining experiences and perceptions of patients after discharge
elucidated that most patients feel that hospital staff does not anticipate enough on the needs of
the patient once in the community (Hesselink et al., 2013). In contrast, the majority of discharged
patients who responded to the HCAHPS survey in this study, stated that staff spoke to them
about the help that they would receive after discharge. This suggests that addressing barriers
to discharge early on allows for better coordination of care in the community.
HCAHP measures that focused on care transitions were rated less favorably before the
intervention. Specifically, patients were less likely to rate “always” under the section inquiring
if they understood the purpose of their medications before the intervention. These findings are
particularly troubling as medication errors at time of discharge have the potential to cause
patient discomfort and clinical deterioration (Wong et al., 2008). A 2008 prospective study
looking at medication discrepancies found that 70 percent of the study group had at least one
actual or potential discrepancy in medication reconciliation at time of discharge (Wong et al.,
2008). Given the enormous potential harm that can come from medication errors, the finding
that the surveyed patients had a better understanding of their medication regimen after
implementation of this discharge intervention is a favorable result (Table III).
The majority of respondents to the HCAHP survey reflected good understanding of
managing their health and what to expect with regards to symptoms and problems after
discharge. This is particularly important as poor understanding of their healthcare after
discharge can lead to adverse events and high-readmission rates (Foster et al., 2003).
In all, 30-day readmission rates not only remained stable throughout the intervention,
they improved after implementation of this discharge planning process. These findings are
consistent with an improvement in patient post-hospital discharge outcomes regardless of a
shorter LOS. This validates the importance of discharge planning and it confirms that
patients were able to safely integrate back into the community and resume community-
based care, despite a shorter hospitalization. These findings attest to the need for early
discharge planning and a multidisciplinary team approach to ensure adequate community
support once the patient is discharged.

Care transitions n August 2013-July 2014 (%) August 2014-July 2015 (%)
Table III.
Hospital staff took preference into account 49 22.6 42.9 HCAHPS care
Good understanding managing health 49 37.5 53.1 transitions
Understood purpose of taking meds 50 40.0 56.1 information
 IJHCQA Additional benefits of this intervention included improvement of team morale, improved
30,2 clinician efficiency and professionalism and improved financial well-being for our IRF.
Some limitations to this study include low response rates on the HCAHPS. This limits the
generalizability of the responses to all patients in our IRF. The results from the HCAHPS
were also biased toward English-speaking patients who could read and write; this is not
representative of our ethnically and educationally diverse population. Rather than
146 rehabilitation outcomes, LOS and satisfaction were used as outcome measures. Future
research should be aimed at using a more quantitative representation of patient health and
functional improvement, such as functional independence measures.

Conclusions
Hospitals have the responsibility to ensure that patients are safely and efficiently discharged
home. This is becoming increasingly important, considering the trend toward shorter stays in
inpatient rehabilitation and more care in the community. Adverse events frequently occur
during the transition from hospital to home that can lead to increased morbidity and
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mortality. The implementation of our discharge intervention including identifying barriers

early in the hospital course and improving communication, resulted in a reduced LOS,
improved patient’s satisfaction with their transition home, and a decrease in short-term
readmission rates. This study demonstrated that a structured discharge plan grounded in
communication and teamwork can improve patient safety during the discharge period.

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Corresponding author
Lisanne Catherine Cruz can be contacted at: lisanne.cruz@gmail.com

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