1. The View Through Different Lenses

2. There are no relevant financial relationships to disclose or conflicts of interest to resolve

3. The single biggest problem in communication is the illusion that it has taken place. -George Bernard Shaw

4. Results of parent interviews Results of primary care provider interviews Identifying measures of change

5. Health care communication is a skill that is critical to safe and effective medical practice and can be taught. 1 Communication is the most common procedure in medicine. Communication is essential for accurate diagnosis, development of treatment plan, is correlated with improved patient knowledge, functional status, adherence to treatment, and reduced surgical morbidity. Levetown, M. Pediatrics, 2008; 121(5): (e1441-e1460)

6. Hospital discharge is the final opportunity for providers to communicate discharge instructions and answer questions. Poor discharge communication contributes to adverse events and increased health care costs. 1-3 Patients who do not follow up are more likely to be readmitted. Forster A, Murff HJ et al. Ann Intern Med. 2003; 138: 161-167 Forster A, Clark HD et al. CMAJ. 2004; 170(3):345-349 Kripalani S, LeFevre F et al. JAMA. 2007; 287(8):831-841

7. Currently have a two silo system. 85% of hospitalists sent discharge information, but only 72% of PCPs report receiving the information. 65% thought the information was complete. 1 After formative work conducted here in the Division of Hospital Medicine, the faxed Discharge Orders and Discharge Instructions were developed and implemented. 2 Leyenaar, J VIP Network Transitions of Care Collaborative, PHM 2012. Harlan GA, Nkoy, FL et al JHQ 2010. 32(5); (51-60)

8. Characterize and define “successful” discharge communication for: Parents of hospitalized children Primary care providers Hospital care providers

9. 8 key informant parents of children with complex chronic conditions with a recent discharge (previous 3 months). Interviews audiotaped, transcribed verbatim and manually coded for emergent themes. Kappa=0.72

10. Themes were clustered into three categories Discharge problems Emotion and uncertainty Parent proposed solutions

11. Long delays between mention of discharge and actual discharge.

12. Insufficient communication with discharging provider at the time of discharge.

13. Home health care communication issues Set up Knowledge of child’s condition Problems with medications

14. Parents expressed desire for better understanding of possible problems and adverse outcomes to watch for. There is a need for more clearly defined contingency plans: who to contact, order of contact, and when to follow up.

15. Scheduling appointments is currently very difficult.

16. Discharge paradox: parents are told that things will be fine at home but they are not OR parents were trained in life-saving techniques that contradict the message that they are safe to go home.

17. I kept hearing that it will be better when you get home. She’ll be at home. She’ll be-- and so, I kept looking for that better. And it wasn’t happening. And I thought well is this better? Is this what they mean by better? Well, when we got home, it was within two days we were back because her shunt failed, but in the back of my mind, I kept thinking no, they said it would be better. So, whatever my gut is telling me is being overridden with the fact that they’re telling me it’ll be better, just give it some time. It’ll be better.

18. Care chasm: the emotional, perceptual and material gap between hospital care and home care that the discharge process is meant to bridge, but often does not.

19. “We know our emergency people now because I’ve talked with them and told them about my daughter. So, I went to where their little ambulance station was, called them and said can I come down? I want to you to meet her. And gave them a little paper about her. And I know there will be a day where we’ll have to call EMS, especially at school. Once they get there and go ‘that’s Cameron. We know her.’ Yeah, so that’s what my hope is.”

20. Care chasm: Complexities. Families do not feel the gap is bridged until seeing PCP. PCPs feel that a connection with any outpatient provider is enough to bridge the gap.

21. Discharge checklists for concrete tasks and DME orders to be completed during hospitalization. Discharge readiness assessment tool. Enhanced intersections between inpatient and outpatient providers.

22. Greater inclusion of the child in discharge planning and teaching. Calls to families post-discharge to make sure they don’t have questions or needs. Parents want to be involved in the development of these solutions!

23. Notification of ICU transfer. Varying preferences for inpatient to outpatient communication. Notifications of any conflict between inpatient team and family.

24. Enhanced discharge orders and discharge information. Includes discharge summary. Completed in real time. Auto faxes to PCP at the time it is signed by the attending physician.

25. Continue to collect and analyze hospitalist and primary care perspectives on discharge. Better PCP identification through electronic means, so that the discharge paperwork is more likely to be received. PCP contact preferences (call, message log, etc).

26. Discharge readiness tool. Condition specific discharge checklists. Partner with out-patient providers for children with special health care needs. PCP call tracking.

27. Discharge communication provides a crucial link between hospital and home. Parents and primary care providers have suggestions for concrete solutions to many communication problems. Family desire for involvement in developing next stage solutions could be the basis for a patient centered outcomes research award.

28. What are we trying to fix? What are outcomes of interest? What could we measure? What would success look like?

29. Families and pediatricians who participated in this study Chris MaloneyLisa Morrise Paul YoungAmanda Choudhary DayValena CollingSarah Decker Cassy WeeksPatient and Family Advisory Council Mike Mundorff Teresa Ostler Howard Parker Elena Dicus Michelle Hofmann