Interactive Patient-Centered Discharge Toolkit To Promote Self-Management During Transitions (Massachusetts)

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Interactive Patient-Centered Discharge Toolkit To Promote Self-Management During Transitions - Final Report

Dalal A. Interactive Patient-Centered Discharge Toolkit To Promote Self-Management During Transitions - Final Report. (Prepared by Brigham and Women's Hospital under Grant No. R21 HS024751). Rockville, MD: Agency for Healthcare Research and Quality, 2019. (PDF, 263.46 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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Incorporating an interactive, patient-centered toolkit, with discharge checklists and videos, into clinical practice with the intention of engaging patients, caregivers, and clinicians to improve discharge planning is feasible, although more research is needed to maximize adoption, use, and maintenance of these tools into routine practice.

Project Details - Ended


Approximately 19 to 23 percent of hospitalized patients experience preventable adverse events after discharge, many that are due to suboptimal monitoring of medical conditions, medication errors, and nonadherence, as well as failure to execute the care plan. Achieving a high-quality transition requires effective understanding of the discharge plan by patients and caregivers, as well as seamless communication with key inpatient providers to address patients’ concerns during and immediately after hospitalization. Use of patient portals in the acute care setting is a promising strategy to engage patients and caregivers during hospitalization, but their use in this setting is new.

To address these issues, researchers refined and implemented enhancements to a previously developed, interactive, patient-centered discharge toolkit (PDTK). This toolkit included a discharge checklist and video, safety dashboard, and secure patient-clinician messaging to engage patients and caregivers in preparing for discharge during their hospitalization.

The specific aims of the project were as follows:

  • Refine and implement an interactive PDTK on a general medicine unit that patients and caregivers can use to prepare for discharge and communicate with key providers during the transition home. 
  • Conduct a pilot study to evaluate the effect of the PDTK on patient activation. 
  • Identify barriers and facilitators of implementation, adoption, and use of the PDTK by patients, caregivers, and clinicians using qualitative and quantitative methods. 

First, researchers conducted informal workflow observations on study units and interviews with stakeholders to identify requirements for engaging patients and clinicians in discharge preparation while aligning with the following priorities: 1) engaging patients to improve patient satisfaction, 2) improving expected discharge date entry in the electronic health record (EHR), 3) increasing discharges before noon, and 4) reducing 30-day hospital readmission. Researchers then used user-centered design principles and an iterative, participatory process to refine key intervention components, including a discharge checklist, a video to help patients understand the purpose of completing the checklist in preparation for discharge, and secure post-discharge messaging. Finally, the research team conducted a pre-post study with adult patients admitted to general medicine units, measuring patient activation at discharge and at 30 days, and utilization of healthcare resources after discharge.

The researchers found that the intervention components were used moderately to highly by patients, but only modestly by clinicians. However, there was no significant change for post-discharge healthcare resource utilization, such as ambulatory visits to primary care physicians, emergency department visits, or hospital readmissions. In subgroup analyses, the primary outcome of patient activation at discharge was higher among post-intervention participants with high socioeconomic and low hospital readmissions scores. Lessons learned should help other institutions implementing EHR-integrated digital health tools to engage patients in discharge preparation, while also addressing workflow challenges.