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Person-centred care is recognised as a key dimension of safe, high quality healthcare. Engaging with patients and their support people at discharge can have a positive influence on patient outcomes through clarity of management plans and by reducing readmission to hospital.

Clinicians should provide written information to patients and their support people, and take time to explain discharge instructions, medicine regimens, and who to contact if they have questions or concerns after discharge. The Teach-Back method is a valuable communication skill to confirm patients’ understanding of the information given to them.

Also see:

• Communicating with patients and colleagues

Clinical handover at discharge often occurs via a written document, usually in the form of a discharge summary. Delays in providing discharge summaries to GPs, pharmacists and community health providers increase the potential to adversely impact the safety and quality of patient care.

From a continuity of care perspective it is important that clinicians ensure that accurate, legible and relevant information is exchanged in a timely manner with the next health provider, and where possible the patient and their support people. Clinicians need knowledge of their health service organisation’s clinical communications processes and policies, including the agreed discharge information requirements, to enable safe and efficient transfer of care.

My Health Record is an electronic summary of an individual’s health information that can be shared securely online between the individual and healthcare providers (who are registered with the My Health Record system) involved in their care to support improved decision making and continuity of care.

Also see:

• Communicating with patients and colleagues
• Documenting information

The Delirium Clinical Care Standard makes specific reference to communicating a care plan for patients with delirium.

Effective communication between hospital clinicians and ongoing clinical providers is essential for the ongoing care and recovery of patients with delirium, many of whom may have unresolved symptoms at the time of discharge.

Before a patient with current or resolved delirium leaves hospital, the patient and their support person should be involved in the development of an individualised care plan and provided with information about delirium. The plan is developed collaboratively with the patient’s general practitioner and describes the ongoing care that the patient will require after they leave hospital. It includes a summary of any changes in medicines, strategies to help reduce the risk of delirium and prevent complications from it, and any other ongoing treatment. This plan is then provided to the patient and their support person before discharge, and to their general practitioner and other ongoing clinical providers within 48 hours of discharge.

As a leader in your organisation, you have a responsibility to ensure that the systems and processes in your organisation support communicating for safety in planning for discharge and in the discharge process itself.

The NSQHS Standards complements the participation requirements as set out in Part 5 of the My Health Records Rule 2016. The rule outlines the participation requirements for healthcare provider organisations and contracted service providers which contributes to the secure operation of the My Health Record system.

Effective communication is a key requirement of the NSQHS Standards (2nd ed.) The following table describes actions in the NSQHS Standard that are relevant to communicating for safety at discharge.

For more information see the NSQHS Standards (2nd ed.)

You have a key role and responsibility to effectively communicate with your patient, their support people and other members of the care team when you are discharge planning, or undertaking the discharge process. This requires knowledge of your organisation’s clinical communication processes and skills in ensuring interactive, two-way communication, building rapport and trust, and explaining information.

Health literacy is important to the safety, quality and effectiveness of the care you deliver. If your patients do not understand the information you are providing during the discharge process they may be at higher risk of experiencing poor health outcomes.

You can ease the burden on your patients through the way you communicate and present information by:

• Assuming that most people will find it hard to understand complex health information and concepts and adapt accordingly (universal precautions approach)
• Recognising the needs and preferences of individual patients and tailoring your communication style to their situation
• Using a range of strategies to confirm understanding
• Encouraging people to speak up and ask questions if they have difficulty understanding
• Providing a written discharge summary to the patient to support the discussion.

Effective communication with your patient and their support people promotes an understanding of how to manage their care when they leave your service and any next steps they need to take.

When information is sent or received between care team members, you have the responsibility to verify, validate, confirm, receipt, communicate and act upon it as appropriate to optimise the safety and quality of care. In particular; clear, legible communication of current and changed medications mitigates the potential for the significant safety risks associated with poor medication management at the time of discharge.

For more information see:

• Communicating with patients and colleagues
• Communicating at transitions of care
• Follow-up communication
• Documenting information
• Health literacy for clinicians

When you are being discharged from hospital:

• Ask your healthcare provider to explain the plan that you will follow at home, any new medicines you will be taking, and whether you need to make any follow-up appointments
• Ask to have your family, carer and/or support person involved in discussions about your discharge from hospital
• Discuss with your doctor or nursing staff any concerns you have about being discharged
• If you have questions that still have not been covered, ask you healthcare provider if there is information you can take with you, or where you can get more information
• Ask for contact details for someone on the ward, in case you have any immediate post-discharge concerns
• If your Discharge Summary* isn’t provided to you, ask for a copy of it.

*A Discharge Summary is a written document that summarises why you came into hospital, the care you received, the plan of action when you leave the hospital, and lists any follow-up appointments. The hospital should send your Discharge Summary electronically to your GP.

Questions you can ask:

• Can you explain to what I need to do to manage my care at home?
• Will I need someone to care for me after the operation?
• How can I find someone to assist me?
• What should I do if my symptoms get worse?
• Who can I contact if I need to speak with someone?
• Will I be given a written discharge plan or care plan?
• Will you send the discharge plan or care plan to my GP?

My Health Record

The Australian Government has invested in the My Health Record system, an online summary of your health information that is accessible at any time by you and your healthcare providers. You control what goes into your record, and who is allowed to access it. Documents that may be securely shared between your healthcare providers include: