Special Report: Improving care transition communication

Transition team deals with risky situations

These scenarios often arise

The hospital discharge process for patients most at risk for readmission would be much simpler if discharge nurses or managers were able to simply explain what a patient needs to do next and know that the patient and family are ready to follow those instructions.

In reality, it rarely works that well.

Hospital discharge planners typically have to navigate situations in which the best care transition plan for a particular patient is the one that the patient or the patient's family members are not interested in pursuing. Or, discharge planners might think a family is on board with a particular strategy, but they learn otherwise when the patient bounces back to the emergency room a few weeks later.

These tricky situations are why the hospital transitional care team needs to learn how to communicate with families and patients when the family dynamics are particularly challenging.

"This kind of work is extraordinarily complicated when you think about the large number of players and stakeholders involved in any decision," says Lori L. Popejoy, PhD, APRN, GNS-BC, John A. Harford Foundation Fellow and assistant professor in the Sinclair School of Nursing at the University of Missouri in Columbia. Popejoy recently published a study about the complexity of family caregiving and discharge planning.1

Popejoy outlines these types of hospital team-patient/family interactions and how communication problems can be avoided:

Scenario: Patient withholds information from some family members. Often, a hospital discharge team will find that the patient and his or her spouse do not want to disclose all of their health information to their adult children, Popejoy notes.

"They live their lives the way they want, and they don't want any interference in their lives," she explains. "Their kids are still their children, and their kids aren't running the show."

The patient's wishes would be honored by the health care team, but the situation becomes problematic when it becomes clear the patient and spouse will need some kind of community/family support. So the hospital team should be very clear in their communication with the patient regarding what kind of additional help he or she might need and whether this help will require assistance from family, friends, neighbors, or other informal caregivers.

"The health care team is respectful of where family members fall on this continuum of what the patient is willing to tell them," Popejoy says.

But patients will change their minds, and some patients might have cognitive decline, suggesting that they are not competent to make their own health care decisions and input from family members is necessary.

"You have to make a judgment call about who is competent and who is not," Popejoy says.

Scenario: Older patient's spouse is too frail to handle the patient's physical care at home. When a patient is admitted to the hospital from home where he or she lives with a spouse, then the couple typically expects to return home at discharge, Popejoy says.

The discharge team might believe a nursing home is a viable option for rehabilitation, but if the couple resists this option, then the situation becomes complicated.

"If they were living with their spouse then they might want to go home with their spouse, and the spouse could be willing to do whatever it takes to bring that person home," she explains. "But as a healthcare provider, you want to make the best choice for the family."

There often are cases where the spouse is at risk physically, particularly when a small and frail wife is taking home a large, elderly husband who has functional deficits, she says.

"He can't walk very well; he can't bathe himself, and there's a danger of the female being hurt inadvertently when caring for him," Popejoy says.

"You'll need to put in a strong personal care plan for that situation," she adds.

The health care team also should communicate clearly the financial responsibilities in implementing this care plan.

Scenario: Patient's discharge expectations clearly are unrealistic. Patients sometimes strongly disagree with the hospital team about Plan A at discharge. For instance, the patient needs complex intravenous therapy, and the discharge team has determined that the patient's family will be unable to provide this care adequately. Yet the patient insists on returning home.

"We have this idea of autonomy and if someone says they should be able to do it, they should be able to do it, but the truth is that people say they can when they can't," Popejoy says. "Then they're turned around and hospitalized because they can't handle it."

The solution here is to speak candidly with the patient and family about what will happen when the patient is discharged.

"We can say, 'This is what it takes to get you up in the morning; right now you're so weak you can't move to your wheelchair, so how will we get you from the bed to the wheelchair when you're home?'" Popejoy suggests.

The discharge planner can explain how the patient will need to be discharged from the hospital before he or she is back to a prior level of functioning, but there is a plan in which the patient could go to a skilled nursing facility for short-term rehabilitation before heading home.

"Then you can tell them, 'When you come home, here are the services that will be reinstated,'" Popejoy says.

Clearly explain that Plan A is to discharge the patient from the hospital to the next level of care and from there to their ultimate goal of returning home. The skilled nursing facility is a bridge to get the patient to that goal, she adds.

"You need to be very clear on what the patient's deficits are and be clear with them about the complexity of the problem," she says. "Usually there's a functional deficit in their ability to care for themselves."

Draw a concise picture of where the patient's current functional status is and what is required for the patient to become independent, Popejoy suggests.

"You can say, 'We don't know if you'll be able to do that, so you need to get stronger and not hurt yourself,'" she says. "Then be clear that the ultimate goal is to go home, and that ultimate goal needs to be articulated to the rehab facility if that's the goal."

Also, the hospital team should reassure the patient that the nursing home stay is temporary because they fear they'll be admitted and then never leave, she says.

Scenario: Patient wants to return home, but adult child is uncomfortable with plan. This scenario is a twist on the theme of patients wanting to return to their own homes and independence.

In this case, a hospital nurse might be pulled aside by the patient's daughter or son, who says, "Can you talk some sense into my mother? She needs to go to a nursing home and stay there, but she wants to come home. It makes me uncomfortable," Popejoy says.

Incorporating these family member's concerns into the discharge plan is tricky because the patient might have expectations that the child will become a caregiver, while the child clearly does not want this role. The best strategy might be to help the patient realize what he or she will need to stay healthy and happy, she says.

Sometimes patients will reject the discharge team's first-choice option of having the patient transitioned to a skilled nursing facility, and the less desirable Plan B will take place.

"In my study, social workers and nurses talk about acknowledging that they sometimes send patients home with the best plan they can, but they knew it would fail," Popejoy says.

If the patient rejects Plan A in which he or she would be transitioned to a skilled nursing facility, then what's left is Plan B in which the patient is sent home with as many support services as can be found. In accepting this less than desirable option, the hospital team should be aware that the patient likely will be returning to the hospital. And when this happens, it might be time to again stress the importance of a nursing facility plan.

"We need a plan that will enable them to be successful wherever they are going, and we need a back-up plan on call," Popejoy says. "If you send the patient home, that might be not the best choice, so what is Plan B going to be?"


1. Popejoy LL. Complexity of family caregiving and discharge planning. J Fam Nurs. 2011;17(1):61-81.