The nursing journey isn't limited to the hospital or the physician's clinic. Nurses' influence extends far beyond healthcare facilities. These hardworking professionals continue to offer support and guidance long after patients head to other clinical environments and even after they return home.
Nurses prioritize continuity of care, with the understanding that patient outcomes largely depend on what happens when patients are not physically present within clinical settings. Their journey to better health is heavily influenced by the handoff process, when nurses set the stage for safe transitions and ongoing communication.
There's a lot to tackle: medication reviews, home care instructions, follow-up appointments, and even ethical challenges. Care coordination in nursing ensures these diverse concerns are addressed, all while helping patients feel informed and empowered. Continue reading to discover more about handoffs in relation to readmission reduction strategies and long-term health management.
A transition occurs any time a patient leaves a specific care setting. This departure may involve a shift to a different ward or unit, but it could also describe transitions between practitioners, such as from primary to specialty care. Major transitions occur as patients transition from the clinical environment to residential facilities or their own homes.
These transitions qualify as nurse-led when RNs or other nurses oversee the transfer process, actively coordinating communication while promoting continuity of care.
These transitions have a documented impact on patient outcomes, as do the errors that take place during transitions. A commonly cited finding from the Journal of Patient Safety suggests that nearly 80 percent of major medical errors relate to miscommunication in the midst of handoffs.
The care boundary represents a critical moment of handoff, when miscommunication becomes more likely and continuity can be lost in the fray. Without precise coordination and clear communication, it becomes difficult for the patient (or caregivers) to discern what should happen next and how care should proceed. This confusion can introduce new risks, making medication errors more likely or even prompting delays in follow-up care if patients lack support in scheduling additional appointments.
Accountability plays a significant role in care transitions, determining who takes responsibility for patients as they navigate various spaces or processes within the broader healthcare system. Without accountability, patients risk getting lost between providers, receiving conflicting information, or even lacking ongoing support altogether. This also makes it challenging to provide the holistic, patient-centered approach to care that is so highly advocated for within the nursing profession. Limited accountability can lead to fragmented care, opening the door to considerable gaps.
Nurses take accountability by verifying that patients understand instructions — and by confirming that essentials such as follow-ups are in place before patients move on to the next phase in their care journey. Nurses who proactively manage patient handoffs can achieve impressive results, including significant reductions in medication errors and readmission rates.
The discharge process should involve a precise and highly standardized series of steps that prioritize clear communication, ensuring patients understand what will happen when they leave their current care setting. While this information (and the manner in which it is shared) must be adapted to reflect the patient's unique needs, discharge instructions must always cover these essentials:
Health literacy determines not only what patients know about health and well-being, but also their ability to find and assess additional information as needed. Nurses can support health literacy by using plain language (free of jargon) and by using visual aids or other tools that clarify complex topics.
An evidence-based practice known as teach-back supports this effort by encouraging patients to actively engage in educational efforts. Under this method, nurses ask patients to repeat important information in their own words, using their own descriptions to clarify critical health topics. If, based on this explanation, it becomes clear that the patient does not fully understand health concepts, nurses can adjust their messaging and try again. Teach-back health literacy efforts constitute a key form of closed-loop communication, prioritizing verification as a means of confirming understanding.
In addition to promoting health literacy, nurses should help patients identify the next steps they can take to continue improving their health from the comfort of their own homes.
For many, the recovery effort will be supported by targeted medications, which nurses can describe in detail along with their potential side effects. Nurses should provide detailed instructions for taking these medications, highlighting the necessary dosages and timing, and any drugs that should be avoided in the meantime. Similar advice may precede the use of medical devices like glucose monitors. Nurses should help patients understand when and how to use these devices correctly and how to interpret the readings.
Depending on the patient's condition, home safety may also be a priority. This may include discussions of common safety hazards in the home, such as obstacles that increase susceptibility to falls. Nurses can help patients assess these hazards and recommend mobility aids or other solutions that enable patients to navigate their own homes safely during the recovery process.
Insights from the Joint Commission Journal on Quality and Patient Safety (JQPS) suggest that two-thirds of nursing healthcare communication failures relate to handoffs. Therein lies the need for structured processes that limit the potential for miscommunication.
Offering a structured approach to the transfer process, the SBAR (situation, background, assessment, and recommendation) handoff facilitates clear and efficient communication. By addressing the various topics nurses must cover, this framework limits the potential for omissions.
The specific details shared may vary depending on the type of handoff or the individuals involved. Still, the basic structure is consistent: clarifying the problem (the situation), offering relevant clinical information (the background), conveying clinical judgment related to the situation (assessment), and proposing actions that resolve the problem (recommendation).
Internal handoffs occur when responsibility shifts from a specific team or clinical professional to another team within the same facility. This includes not only shift changes, but also transfers to other departments and transitions between various levels of care.
A common example involves the shift from bedside care to the discharge team, which preps patients for additional handoffs later on. Discharge teams require patient-specific information to prepare patients for future transitions effectively.
Cross-setting handoffs occur when patients move from one facility to the next — or when they transition to their own residences to receive postoperative home care. These moments can introduce significant challenges, especially compared to internal handoffs.
Differing EHR systems may be involved, for example, along with distinct communication protocols. Organizational culture can influence care transitions. For instance, it dictates whether nurses or physicians lead these transitions and shapes patient care priorities, such as focusing on stabilization over functional recovery.
Cross-setting handoffs can be improved via widely utilized communication frameworks (such as the previously discussed SBAR) and by improving EHR interoperability. Nurses can improve these processes by maintaining precise documentation and prioritizing direct handoff communication through secure platforms or portals. Tools and templates (such as an SBAR handoff template) can standardize transitional strategies to promote consistent communication.
Research shows readmissions often occur within seven days of the patient's discharge. Known as rapid readmissions, these returns are closely linked to morbidity. They can be prevented through follow-up regimens that prioritize both timely responses and aligned, thorough communication that addresses all relevant components of patient care.
The seven-day follow-up serves as a crucial checkpoint, during which potential complications can be identified and addressed before they escalate into more significant problems. While the follow-up appointment itself can be enlightening, it's far more impactful if previous discharge efforts have provided a baseline to bring greater clarity to the current status of the patient in question.
Amid the upheaval of returning home and beginning the complex journey of self-management, patients may forget to schedule follow-up appointments. Therein lies the value of scheduling before discharge, with this ideally taking place well before patients leave. In addition to scheduling in-person appointments (or home health visits), nurses can arrange for post-discharge follow-up phone calls, which provide additional opportunities to address patient concerns.
The seven-day follow-up and the post-discharge follow-up phone call form the basis for strong communication after patients return home. Additional touchpoints should be made available, however, allowing patients to seek insight into evolving symptoms or potential changes in regimens. Technological innovations can expand these opportunities, including patient portals and automated text messaging programs.
When planning handoffs, nurses should be mindful of the social determinants of health (SDOH) and their potential impact on patient recovery. The SDOH shines a light on everything from socioeconomic status to housing stability and even healthcare access. Understanding their impact on individual clients can help care teams address barriers to care by coordinating resources and providing tailored support.
Nurses screen patients for a variety of factors that could potentially increase patients' risk once they are discharged. This enables them to identify potential issues early on and assist patients in accessing the appropriate resources based on their concerns.
Many screening tools and techniques support this effort. For instance, the Blaylock Risk Assessment Screening Score (BRASS) delves into social support and active medical problems, which then inform discharge planning needs following hospitalization. Increasingly, nurses rely on social determinants screening to identify factors that may negatively impact recovery and to build these concerns into discharge planning.
Referrals help patients access specialty care within other areas of the healthcare system. This is often critical during care transitions, which may involve a shift towards addressing specific clinical needs such as cardiac concerns or mental health challenges. Nurses can contribute to this initiative by utilizing screening tools to identify unmet needs and working with various care teams, even if making direct referrals falls outside their individual scope of practice.
Nurses are expected to log a wide range of discharge-related activities, keeping detailed records to promote transparency and accountability. Feedback loops support the flow of information, ensuring that the right details reach the right clinical professionals. This should be purposefully built into nursing workflows to ensure consistency and to limit associated administrative burden.
Successful handoffs rely on clarified roles and responsibilities, with all team members understanding which tasks they are expected to handle and how, through precise coordination, they can provide streamlined care.
Registered nurses play a central role in transitions of care, but many other clinical professionals are also involved. Dedicated care coordinators or case managers may support this process by addressing logistical concerns, such as helping patients access transportation or necessary medical equipment. Physicians support discharge by reviewing treatment plans, while pharmacists' medication reviews drive a greater understanding of dosages and side effects. Every role should be clearly defined, as should the channels of communication between various healthcare and allied health professionals.
Debriefings (known as huddles) encourage nurses to communicate about various challenges, including operational difficulties. During these meetings, nurses can reflect on previous handoffs, clarify plans for upcoming transitions, and identify potential bottlenecks.
Patient rounds provide additional opportunities to review care plans and make adjustments. These set the stage for successful handoffs by ensuring that all nurses are up to date on patient progress, including not only changes in condition, but also new interventions.
Through careful tracking and documentation, nursing teams can gain valuable insights into the practices that promote patient health during and after handoffs, revealing where improvements are needed and how, specifically, these can be achieved.
Metrics enable nurses to assess transitions, determining their short-term safety and effectiveness, as well as their ability to foster positive long-term outcomes.
A top indicator of quality? Readmission rates, which indicate whether patients eventually return to facilities for intensive care. A low 30-day readmission rate suggests that patients have received enough information and support to manage their care at home, and hopefully, to avoid urgent issues that lead to further hospitalization.
Patient satisfaction scores reveal whether patients feel respected and cared for during transitions. Helpful insights may be available through Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, which reveal how patients feel about their interactions with nurses and physicians.
Learning systems offer a structured approach to evaluating metrics and utilizing this information to drive necessary improvements. The Plan-Do-Study-Act (PDSA) cycle, for example, can help healthcare teams test changes and refine workflows before implementing them on a broader scale. Quality improvement tools like PDSA worksheets guide nurses through this process.
To reinforce insights on effective discharge and improve handoffs and continuity of care, learning collaboratives and professional development programs can be implemented. These initiatives encourage nurses and other healthcare professionals to collaborate and share lessons learned.
Advanced technologies support safe and effective handoffs by enabling healthcare professionals to document the process in detail — and access this information across various care settings.
Electronic health records play a vital role in the modern discharge process. Many platforms offer built-in handoff tools or modules, which encourage nurses to record patient information consistently. These tools may incorporate templates, checklists, or other tools that help nurses avoid omissions. Nurses can also use discharge planning software to track pending activities and coordinate follow-up care. These days, AI-powered solutions can even pinpoint gaps in care plans.
Remote monitoring enables nursing teams to identify when patient conditions change and when additional support is needed. This effort is increasingly involving wearable devices, which can track vital signs and other health indicators to provide early warning signs of complications. Real-time data analysis supports alerts that may be triggered if patients move beyond specific thresholds or safe ranges.
While the handoff regimens discussed above hold widespread value across the continuum of care, these strategies may need to be adjusted to reflect specific patient concerns. Certain conditions, for example, may introduce elevated risks following handoff, influencing processes such as the home health referral process and medication reconciliation at discharge.
Following surgery or other invasive procedures, nurse-led transitions become incredibly important due to increased risks of severe complications that lead to readmission. For instance, following heart failure, fluid retention must be top of mind, with weight monitoring prompting early detection and prompt interventions. With diabetes incidents (such as hypoglycemia or hyperglycemia), insulin and dietary management are prioritized via diabetes discharge education. Transitions to postoperative home care often emphasize both pain management and infection prevention.
Discharge teach-backs should encourage patients to discuss (in their own words) why they were hospitalized and which steps they should take upon return home — such as taking the proper medications or using medical devices correctly. Teach-backs should also clarify situations in which patients should call for help.
Nurses should use standardized SBAR templates to transmit critical information via secure EHR systems. Confirmation of receipt should be provided, with escalation to the care coordinator occurring if acknowledgment is lacking after 24 hours.
Adverse events and medication errors are most likely to occur in the first seven days following discharge. Early interventions can be staged if patients are seen or contacted within this window.
Nurses may conduct post-discharge calls or by pharmacists using scripts. These calls should emphasize medication adherence while providing opportunities to clarify care instructions.
Nurses can accommodate patients with limited health literacy by using visual aids and bilingual materials when necessary. Explanations should use simplified language, with teachbacks confirming patient understanding.
Metrics such as 30-day readmissions and 7-day follow-up adherence provide clear indications of patient status and engagement following discharge. Healthcare providers should also monitor for SBAR documentation and teachback completion.
Nurses can address socioeconomic challenges by completing SDOH screenings and connecting patients to transportation services or food resources. Referrals should be recorded, along with confirmation that these have been received.
Expand your care coordination skill set as you pursue your bachelor's in nursing, or even your doctorate, with Indiana Wesleyan University. Emphasizing evidence-based practice and patient-centered care, our nursing programs provide accessible pathways that encourage growth, skill development, and personal reflection. We even offer opportunities to explore nurse entrepreneurship and other innovative solutions.
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