This week I counseled a 71-year old gentleman who was recently hospitalized for uncontrolled blood sugars in the 500-600 range about health literacy. He has had diabetes for almost two years which was controlled with oral diabetes medications until this recent event. He had an underlying infection in the heel of his left foot which raised his blood sugars requiring insulin treatment in the hospital. At discharge he and his wife were told to continue the insulin regimen at home which was never followed. Unfortunately, he was not seen by his primary care MD in the hospital and there was very little communication when he was discharged.
Although his wife is extremely intelligent, and always present and dedicated to his care, he had been off insulin for the following 10 days when he was home. Luckily, after some quick detective work I was able to understand which types and amounts of insulin he needed by checking with his primary care doctor who received his hospital discharge summary. He is now following the correct insulin protocol, his blood sugars are improving, and the infection is resolving with proper out- patient wound care and antibiotics. This could have had an unpleasant ending requiring another hospitalization. I wanted to share some insight into hospital discharge planning to help you prepare in the event that you end up hospitalized.
The health care system pays more than 17 million a year for preventable hospital readmissions. Being proactive as a patient, along with having a patient advocate with a good understanding of the discharge planning information, may have a positive effect on the entire health care world. One of the biggest problems facing American healthcare today is the readmission of patients to the hospital for the same medical reason less than 30 days from the original admission due to “health illiteracy”. Health literacy is “the degree to which an individual has the capacity to obtain, communicate, process and understand basic health information and services to make appropriate health decisions”. Health literacy is especially critical when patients are discharged from the hospital and self care must take over. Over 40% of patients over 65 end up with medical errors when home and 18% of Medicare patients are readmitted within 30 days for the same medical problem. The discharge instructions which guide the patient at home are the focus for patient compliance. According to the American Medical Association (AMA) “the information should be presented on a sixth grade reading level but is often offered at a tenth grade reading level”. The fact is only 36% of American adults have adequate “health literacy skills”.
Unfortunately, to make matters worse, although the AMA and The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) offer discharge planning recommendations there is no universal system in US hospitals. “Money is made when the patient is in the hospital bed and not when they are discharged”. It is no secret that hospital stays are shorter and patients are being released “quicker and sicker”. Many times there is a lack of consistency between all the medical providers consulted and the take home message after a hospital stay. Often patients are frustrated, embarrassed or afraid to ask questions and say “yes” to the discharge instructions because they just want to get home. Once home, they have minimal understanding of what needs to be done to help them fully recover. Another common problem with current discharge planning is “the tear sheets given in a 20-page packet offering general information and no specific patient guidelines”. Patients over 65 (have a 12% literacy rate) have many more problems than just literacy issues. Elders suffer from hearing loss, visual acuity, memory problems, easy confusion as well as diminishing concentration levels which makes it even more difficult to follow discharge teaching and planning. Patients may have the literacy skills and comprehension, but due to the stress of the illness and possible complications, mental anguish and fatigue may take over. Since patients with diabetes often suffer from a litany of complications (kidney, nerve, gastro paresis, heart) requiring hospitalization, follow along below for recommendations to make your hospital discharge as safe and smooth as possible.
Remember that the physician is the only one to “authorize hospital discharge” but the orders are generally carried out by another health professional, usually a nurse.
Plan to Follow Up
Make sure there is a plan to follow up with your primary care physician within 2 days following discharge. Have this appointment set up while still in the hospital. Most times patients are followed by an intensivist or hospitalists during their stay. Your own MD is most familiar with your medical history and should know what was done and what needs to be done at the follow-up. Make sure that your discharge summary is printed off for you to take to the appointment or that the summary was sent electronically so you can discuss all aspects of your hospital care at the office visit.
Health Literacy – Ask Questions
Understand that teaching should start at hospital admission and not only at discharge. Ask the staff questions immediately if you do not understand. The patient mentioned above received 4 insulin injections daily without any demonstration in a “teach and learn scenario” probably due to time constraints on the nursing staff. Even if he knew he was required to take insulin at home he would not have had a clue on how to inject. Ask for verbal explanations, written instructions, picture handouts and technique demonstrations for the best learning conditions.
See if your hospital offers an “exit visit” with a hospital pharmacist and take full advantage of this service. The pharmacist will come to the bedside and review all your present medications. You can ask for a print out which lists all the medication names, actions, timing, taken with or without food and side effects. You can find out if the pills need to be swallowed whole or can be split, chewed, crushed or dissolved in a fluid. You can inquire about drug interactions with OTC products, herbal formulations, vitamins or mineral supplements. The pharmacist is an excellent resource person and can review insulin and injectables with you as well. At discharge, medications need to be “reconciled” meaning a final list of previous and new medications are compiled and should be given to the patient. Request two copies so you can keep one at home and one in your wallet or purse. If you drink alcohol, ask the pharmacist if any of the new or existing medications interact with alcohol. Remember that most medications for blood pressure and diabetes are filtered by the liver as is alcohol. The latest research states “that alcohol may blunt the immune system especially in the elderly (65 or over) so consider giving up drinking until you are fully healed after your hospitalization.
Check to see if the hospital has an outpatient pharmacy so you can purchase all new prescriptions prior to discharge. Most patients feel too weak or uncomfortable to stop at a pharmacy on the drive home. Make sure you also have extra written prescriptions or that the prescription is sent electronically to your medication provider. Many hospitals also provide OTC products such as glucose tablets and glucose monitoring supplies in their pharmacies (for a fee) to get you home even more quickly.
The Language Barrier
Language may be a barrier and if so, make it known. Many patients speak fluent English but are more comfortable reading in their native tongue. Hospitals offer written materials in multiple languages so take handout information in the language that suits your needs. Ask for pictures which can be understood in any language.
If you are not comfortable speaking or listening to English, ask for an interpreter. Many hospitals have multi-lingual employees especially in the most common foreign languages, such as Spanish, Creole, Portuguese, and French, and if there is no one on staff to interpret they are required by law to have access to a phone line interpreter in every language.
Interaction is Key
Try to interact with the staff and feel part of your own care as much as possible from the beginning of your admission. Diabetes is mainly managed by you, the patient. Talk to the nursing staff about the “teach back method”. They will first demonstrate the technique such as testing blood sugars or giving an insulin injection and then want you to perform the task in their presence. Try to have a family member or friend present to reinforce the learned behavior especially since you may be tired or stressed.
When given written discharge plans ask for a highlighter and highlight the things that pertain to you on the instruction sheet. Ask the discharge planner to sit with you and review what is highlighted.
Hospital Case Managers and Social Workers
These professionals are generally included in discharge planning and are wonderful resources. They can help when extra services or equipment is needed at discharge as they can order are hospital beds, shower chairs, oxygen set-ups, bedside commodes, wheel chairs or walkers. They can help coordinate services at home including physical therapy, occupational therapy, wound care therapy and dressing changes or regular home health care nursing visits. Social workers and case managers will help, along with the physician, decide if you will receive services at home or go to an out-patient setting for your follow-up care. Case managers can help with suggestions and placement into nursing homes or rehab centers if going directly home is not an option. They can help you decipher your specific benefits offered through health insurance plans. They can talk to you about obstacles in the home including steps and stairs, area rugs and electrical cords as well as the need for ramps or grab bars. They can suggest a dietician come to your home and help plan grocery lists. They are usually available 7 days a week.
Ask More Questions When Home
If you go directly home, the hospital staff usually calls 24 hours and 72 hours after discharge to follow up. Be honest and do not say “everything is fine” if it is not. Ask questions and get proper answers. They will document your progress and it will become part of your permanent record.
Make sure if you are the caregiver you are capable of what is needed. Be honest about what you can and can’t do. Consider your own health, physical condition, finances and work or child care responsibilities. Make sure you understand all the discharge directions. If you can not fulfill all the expectations, the staff may be able to offer more immediate home health care, aid, or nursing services.
Get Help From Community Services or Family Member’s and Friends
When home you may want to look into community organizations which may assist with transportation, counseling for patient and caregiver, support groups or prepared meals. All these services will take a load off the patient and care giver.
If community organizations are not available, consider getting help from family members or friends. Do not be shy, as the patient or caregiver, to ask for help from those in your inner circle. Many people feel funny asking if you need help but will jump to the responsibility when asked. Friends and family members often set up meal and transportation schedules as well as social visits to take the pressure of the primary care giver.
Discharge planning is an important aspect of your hospital stay. It often is the difference between getting well at home in a timely manner and possibly returning directly to the hospital. Be the patient who knows what and when to ask so you can have a speedy and complete recovery!
Have a question or comment? Post below or email me at RKleinman@adwdiabetes.com if you would like to share them with ADW diabetes.
NOTE: Consult your Doctor first to make sure my recommendations fit your special health needs.
She is a member of the American Diabetes Association as well as the South Florida Association of Diabetes Educators. She worked with the education department of NBMC to help educate the hospital's in-patient nurses about diabetes. She practices a healthy lifestyle and has worked as a personal fitness trainer in the past.
She was one of the initiators of the North Broward Diabetes Center (NBMC) which started in 1990 and was one of the first American Diabetes Association (ADA) certified programs in Broward County, Florida for nearly two decades. Robbie has educated patients to care for themselves and has counseled them on healthy eating, heart disease, high lipids, use of glucometers, insulin and many other aspects of diabetes care. The NBMC Diabetes Center received the Valor Award from the American Diabetes Center for excellent care to their patients. Robbie has volunteered over the years as leader of many diabetes support groups.