Discharge Begins at Intake

Communication tactics that help patients transition and shorten stays and reduce readmissions

Nancy Michaels

Nancy Michaels

More about Author

In 2005, Nancy was the picture of success: a sought-after business speaker, the president of her own company, and a mother of three. Suddenly, Nancy found herself in a health crisis that would twice nearly end her life. Miraculously, her extensive rehab left her with no residuals; but, Nancy's life – and the message she wanted to bring to her audiences – were irrevocably changed. Nancy can be reached at nmichaels@nancymichaels.com

Keeping the patient and family members at the forefront by pro-actively communicating with them will automatically allow for more satisfied, engaged and an overall more positive experience for patients and their families.

Whenever I work with a hospital or healthcare system to help them with communication processes, I introduce this concept created by business guru and author, Steven Covey, that states “begin with the end in mind.” This approach of reaching effective outcomes works with establishing and reaching most project management goals and objectives.

With patients and their family members, the idea of discharge beginning at intake makes sense so as to not offer up any unexpected surprises, but to clearly articulate what a patient and family member(s) should expect starting with the intake process. Share the procedure's timeline, the expected length of the stay, what to expect at discharge (to the best of our abilities) with your patient ahead of time, not in real time, as things are happening.

When this is done effectively, patients have a better understanding of what to do prior to a hospitalisation (assuming there’s time for an intake; if that’s not the case, then the ‘intake’ could be explained to a family member or friend on behalf of the patient) and are not upset when it’s the expected time for them to return home. Most of us are compliant and want to be when we know what to expect.

Here are a few suggestions to help prepare a patient and their caregivers with their course of treatment, preparation prior to entering the hospital and discharge plan that can be ideally delivered prior to their hospital stay or to family members in emergency situations

1. Preview Expectations with Patients & Family Members

I learned the concept of previewing expectations from my son’s behaviourist when he was only four years old. I had a suspicion that Noah was on the autism spectrum from only a few months of age. As a toddler, Noah’s speech delays caused him (and the rest of us) much frustration and resulted in behavioural issues that needed to be addressed. He would often hit, spit or go into uncontrollable temper tantrums. Loud noises like police sirens or toilets flushing caused him pain or discomfort and he would cover his ears. Crowds also bothered Noah, and we noticed his ‘behaviours’ increasing. When Noah was four, we were able to have him evaluated by a renowned neuropsychologist, who diagnosed Noah’s symptoms as presenting like Asperger’s Syndrome – on the autism spectrum.

We sought out the help of a child behaviourist, named Janice, to assist us with Noah at home and at school. We did and it was life-changing for me. Janice came to our house very early one morning at 6:30am just in time to witness me serving Noah his breakfast. As most mornings went, I placed Noah’s scrambled eggs on the table in front of him and he’d take his hand and throw the plate off the table leaving eggs strewn throughout the kitchen. I was at my wits end. And by this time had learned to use plastic plates

Janice witnessed what happened and simply whispered to me, “Nancy, make him the eggs again and tell him that you’re going to give them to him, before you put it in front of him.” I made the eggs again and before I placed the dish in front of him, I said, “Noah, mommy made you eggs for breakfast, here you go.” He lifted his fork and began eating. What? Impossible I thought. How did this happen? What had I been missing all this time?

Janice explained that the breakfast scenario was a very short-term example of ‘previewing expectations.’ In other words, by letting Noah know that breakfast was about to be served – as opposed to simply placing his breakfast in front of him – he was able to prepare himself for the meal he was about to receive. She told me that the concept of ‘previewing expectations’ would work with everyone in my life. For example, when going to the grocery store with your three children give them a preview in the parking lot by saying “if everyone behaves and doesn’t throw things into the cart – when we get to the checkout line, I will allow you each to get one candy.” It worked like a charm with all three of my children.

I was a critically ill patient a few years after working with Janice when I was diagnosed with organ failure and had an emergency liver transplant within one week of going to my local ER and being transferred to the critical care unit of a major Boston hospital. I now know first-hand the benefit of this approach and train healthcare professionals and systems in the art and craft of practicing the theory of ‘previewing expectations’ with patients and family members.

2. Decreasing Fear through Pro-Active Communication

As a long-term patient there were many hours, days, weeks, and months that I had time to think – a lot. I often felt that I was in a continuing state of not knowing. Not knowing about what the next procedure might be. Not knowing when I’d be able to breath on my own when I was coming off the ventilator (super scary). Not knowing when my family or friends might be visiting? Not knowing when my doctor would do his or her rounds and not knowing if they’d share any good news that day. The list was endless.

What made things worse, is that there were times when I’d be told something was going to happen (i.e. CT scan, MRI, biopsy, etc.) – but it was hours or days later when it actually did occur. The worst was when I was told I’d be taken off the ventilator the next day (after being on it for about 30 days) and it was four days later when that happened. That’s very unnerving to a patient who hasn’t spoken a word in the three terrifying months as an ICU patient.

Knowing what to expect and what may be needed – a family member or friend to be with the discharged patient, medical appointments that need to be kept, open lines of communication with a doctor or nurse practitioner with a direct phone number that someone will answer the call to answer your questions, are all helpful in easing patients and family member’s level of anxiety that can’t help but shorten stays, increase satisfaction and decrease recurring admissions.

3. The Case for Over Communicating

More communication – even repetitive communication – helps patients and family members better understand what your expectations are, and can prepare them mentally and physically for what’s to come. Taking the time to communicate what they can expect allows for more positive outcomes.

I realise that healthcare providers want to provide consistent communication throughout the process and it may be the ultimate goal of healthcare, but I also know first-hand that doesn’t always happen. For me, my anxiety increased primarily after my family left and I was experiencing pure panic about my physical and mental state. Would more consistent communication have made things less stressful for me? Would it be for my family? Would it work for other patients?

I firmly believe it would and have heard from others that it goes a long way in calming nerves.

4. Breakdown Silos between Departments

One of the greatest fears of patients and family members is that their medical team is not in communication with one another. Our idea oftentimes is that there are too many cooks in the kitchen and does anyone really know what the other division is doing?

Chances are that you are all speaking regularly and very much aware of what needs to be addressed with each unique patient you care for. As crucial as it is for departments/physicians treating the same patient to communicate with one another, this dynamic interaction needs to be communicated to the patient as well to ease doubts, fears and discomfort. We simply don’t know what if anything is being addressed between a team unless that is clearly articulated to us. Please share what the ‘collective’ course of treatment is working towards. We so appreciate the effort of anticipating our anxieties and keeping us aware of what is happening.

5. Be Present and Aware of the Situation You are in and that Your Patients are Experiencing

Time management is important for everyone in a medical setting; however, if you feel rushed, your patients will sense that. If they are not comfortable asking questions because it would take extra time, it will lead to confusion and discontent later on for everyone.

6. Truly Listen

You’re already doing that with each interaction you have with a patient. The best way for your patients or a family member to know you heard them is to paraphrase, repeat important question or key concepts back to them to ensure you've heard their concerns correctly. When responding to your patients or family members, start by saying, "what I hear you saying is.. ., is that correct?" We remember more of a conversation when we paraphrase and repeat back. It also allows for misinformation or understandings to be cleared up on the spot and not escalate with missed assumptions.

During intake or early on in a patient’s hospital stay, it’s wise to revisit what the plan is so there are clear expectations of what will happen should everything go according to plan.

7. Practice being Empathetic

The ability to put yourself in the bed of your patient or the mindset of a family member and deliver messages in the way you would want someone to tell you or a loved one news about your health is a good start to being empathic.

When people know you care, the level of trust increases and improves the overall situations tenfold. If a patient or family member is resisting a discharge, hearing them out with an empathetic tone shows a level of compassion and understanding that is helpful when it’s your turn to explain the benefits to the patient of being able to leave the hospital and to feel positive about that.

8. Take it From the Top — Leadership can Instill Compassion

Compassion and human understanding needs to come from within the top of the organisation and shared with everyone in the health continuum. To doctors, nurses, technicians to maintenance people, the culture of compassion begins within and throughout the leadership and permeates throughout an organisation and is delivered to the end user — the patient and their family or caregivers. We feel it and appreciate the kind gestures, tone of voice, words of encouragement and pro-active communication.

9. Remember: First Impressions are Made within Seven Seconds . . . or Less

Always try to make the best possible first impression always. Clean clothing, well-groomed nails, hands, hair all go into making a positive (or not-sopositive) first impression. In healthcare especially, these first impressions matter most. They also add to the credibility and believability of what you say. Non-verbal presence and communication are critical in winning people over and your ability to speak with credibility.

10. Put Conversations and Questions In Context

Many conversations with patients and their families can be difficult or uncomfortable. Attempt to normalise situations by asking permission to share results of tests with them, or get answers to questions that you need to know and could potentially be frightening to a patient or family member. By saying, "we have to ask all patients these questions when they enter the hospital, so I hope you don't mind me asking a few questions now, is that ok?" This reduces fear and allows patients to feel that they have more control in situations where they have very little.

Imagine if – in the healthcare market – every patient and their family members had expectations previewed for them so they had a good idea of what to expect – at the very beginning – during intake – or even pre-admission? What if the previewing of expectations continued during their (hopefully short) stay and prior to discharge?

When people know what to expect their anxiety levels decrease – their stress goes down. When stress diminishes, so do anxious conversations, demands and complaints to and about medical and non-medical staff. Money is saved and patients are more content across the continuum of healthcare. It’s a win-win-win scenario. Stays may be shorter and readmissions decrease. Isn’t that what value-based healthcare is all about? Keeping the patient and family members at the forefront by pro-actively communicating with them will automatically allow for more satisfied, engaged and an overall more positive experience for patients and their families with these points in mind.

--Issue 40--