Streamlining the Hospital Discharge Pathway: Improving Care Coordination and Patient Outcomes

The hospital discharge process is a critical time for patients, as they transition from the acute care setting back into the community. A streamlined, well-coordinated discharge can help ensure patient safety, improve outcomes, and reduce preventable readmissions. However, inadequate discharge planning and poor communication between providers often lead to fragmented, sub-optimal care. This article examines strategies for optimizing the hospital discharge pathway through enhanced care coordination, education, and follow-up.

The Challenges of Hospital Discharge

Discharging patients from the hospital comes with many potential pitfalls. Often, medical teams discharge patients while they are still dealing with acute medical issues, requiring careful follow-up to avoid complications. The care transitions from hospital-based teams familiar with the patient to community providers who are just getting up to speed. This handoff of information is prone to failure, as discharge summaries may lack key details or fail to transmit to outpatient providers in a timely manner.

Patients themselves may not grasp important self-care instructions, medication changes, or warning signs to monitor post-discharge. If patients leave the hospital without the tools and knowledge to manage their condition, adverse events become more likely. Rehospitalization rates are high, with around 20% of Medicare patients returning within 30 days. Many of these readmissions are preventable with improved transitional care.

The Hospital Discharge Planning Process

High-quality discharge planning starts early in a patient’s hospital stay. It involves a multidisciplinary team including nurses, social workers, case managers, pharmacists, rehab specialists, and physicians. The goals are to identify needed post-acute services, coordinate follow-up care, educate the patient, and ensure safe medication management.

Key steps in effective discharge planning include:

  • Early assessment – The team evaluates expected care needs after discharge within 24 hours of admission. Social determinants of health are identified.
  • Treatment planning – Providers develop the treatment plan with post-discharge needs in mind. Timely consults are made to services like home health, outpatient rehab, or skilled nursing facilities.
  • Patient education – Nurses review diagnosis, medications, self-care needs, and red flags to report. Teach-back education is used to confirm understanding. Educational materials are provided.
  • Discharge summary – Doctors complete a comprehensive discharge summary within 24 hours, including treatment, recommendations, and medications. This is sent to the primary care provider.
  • Medication reconciliation – Pharmacists provide medication education, prescriptions, and facilitate medication access. High-risk meds are reviewed.
  • Follow-up – The care team schedules timely follow-up appointments with primary care doctors and specialists. Care coordinators confirm patients kept their appointments.

Optimizing the Discharge Process

While traditional discharge methods have focused heavily on the handoff of information at discharge, emerging best practices recognize discharge planning as an integrated, patient-centered process. Key strategies for optimization include:

Improving communication – Communication breakdowns are a major contributor to poor discharge outcomes. Strategies include requiring discharge summary completion within 24 hours, coordinating case conferences with outpatient providers, and utilizing integrated health information exchanges to seamlessly transmit records.

Increasing patient/family education – Starting education early, using teach-back methods, scheduling post-discharge reinforcement calls, and referring high-risk patients to care transition programs improves retention of discharge instructions.

Standardizing discharge checklist/protocols – Standardized checklists ensure clinicians address all critical discharge components, prompting them if they miss steps. Checklists also improve teamwork and reduce variation in quality.

Promoting medication safety – Pharmacists providing in-depth medication counseling, fixing errors, reviewing high-risk medications, and facilitating access to meds increases compliance and reduces adverse drug events.

Scheduling prompt follow-up – Follow-up within 7 days, especially for high-risk patients, helps identify post-discharge issues early. By coordinating home health visits and calling patients when they miss appointments, providers close gaps in follow-up.

Developing transition of care clinics – Dedicated clinics staffed by multidisciplinary teams provide intensive management for discharged patients at high risk of complications and readmission.

Leveraging health information technology – Technologies like telehealth, patient portals, and remote monitoring enhances access, communication, and oversight between patients and providers.

Measuring Quality and Outcomes

Robust data collection and analysis enables organizations to identify areas for improvement in their hospital discharge and transitional care processes. Key metrics to track include:

  • 30 day readmission rates
  • Post-discharge ED utilization
  • Timeliness of discharge summary completion
  • Percentage of discharged patients seen for follow-up within 7 days
  • Post-discharge complication rates
  • Patient satisfaction with discharge process

Organizations can benchmark their performance against other institutions and national standards. Data should drive interventions to continually refine the discharge pathway.


Safe hospital discharge and effective transitional care is crucial for avoiding preventable adverse events and unnecessary rehospitalizations. Optimizing the discharge process takes an organization-wide focus on high-quality, integrated care coordination. Investment in discharge planning improvement efforts results in better patient outcomes, reduced costs from avoidance of readmissions, and increased patient and provider satisfaction. Through a patient-centered, team-based approach, hospitals can ensure patients fully understand their post-discharge needs and have the resources and supports to successfully transition home after a hospital stay.

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