Teaching Keys on the Morning of Discharge

The Agency for Healthcare Research and Quality recommends that care teams confirm education on the day of discharge, and for good reason.  

An observational study of the discharge process found that 80% of the patients got no education prior to that morning. There can be many reasons for this; care plan changes can prevent complete information being available before discharge. It can also be difficult to predict discharge, meaning pre-teaching is not always possible. 

The researchers identified shortcomings when observing discharge teaching:

• More than half of patients who had a medication change were not told the reason for it. 

• Around half of the patients were not told the reason for their follow-up appointments.

• More than half of the patients received no teaching about managing their health conditions. 

• 82% of the patients were not taught about red-flag signs that might suggest their condition was worsening. 

The study also found that, most of the time, staff didn’t check if patients had barriers to following their care plan, didn’t ask if patients understood the teaching they received, and didn’t ask if patients had questions. 

While this was a small quality improvement study covering a single morning in two hospitals, it helps highlight teaching gaps that could potentially exist in many healthcare systems. With 15% of all patients readmitted within 30 days, this study’s findings are certainly good to consider as we explore the importance of teaching at discharge.

Using the science of learning to reduce readmissions

How can we help patients learn better while taking full advantage of the morning of discharge? We can start by understanding how the brain learns new information.

When your patient encounters a new piece of information — say, target blood sugar numbers — it’s first stored in their short-term memory. You may be surprised to learn that short-term memory only lasts for 15-30 seconds.  In order to retain the information longer, and be able to use it after discharge, your patient’s brain has to decide to hold on to the new information. 

The brain does this by building neural pathways that strengthen the connections, or synapses, between specific neurons. How easily your patient recalls information, and how long it “sticks in the brain,” depends on the way their brain interacts in a deeper way with newly-learned information and builds these connections.

Using the learning process for better discharge teaching

If you simply tell patients information, it may skip across the surface of their thoughts like a flat stone on a pond. To make it “sink in,” engage the brain by creating what learning psychologists call “desirable difficulty.” While the information itself should be easy to understand, your patient’s mind still needs to do some work. The more the brain interacts actively with the information, the more likely it is to build neural connections. 

Here are some ways you can build desirable difficulty into your patient education:

• Have patients draw diagrams and take notes to connect the information to an action. 

• Use multiple teaching sessions if possible. This takes advantage of the spacing effect — reinforcing neural connections each time you return to the information.

• Try teaching several concepts per session with a short amount of time spent on each. This is called interleaving. It creates more opportunities to return to concepts after some processing time, while making the most of the time you have. 

• Use teach-back to both check knowledge and encourage active learning. In the observational study, only one provider used teach-back — highlighting a significant opportunity. 

• Use a variety of methods, including: pictures, written descriptions, and hands-on practice to activate multiple areas of the brain. 

• Have patients describe how they will apply the information in a real-life situation. When patients connect new learning to prior experiences, they tie the information to something they already know — making it easier to recall later. 

The morning before discharge is the culmination of this learning journey.  It is a time to both check and solidify knowledge. During this check, patients also benefit from situational recall — remembering information because it’s tied to a specific event or location. If you think of hospitalization as a "memory palace," the morning of discharge can serve as an anchor point for patients recalling discharge instructions later.

What to cover on the morning of discharge

When the morning of discharge comes, patients should know how to manage their health, what steps to take next, and what to do if they run into complications. Whether or not you have been able to pre-educate patients throughout the hospitalization, be sure to cover the following before the patient leaves: 

Medication changes. Let them know which medications are new, which were stopped, doses changed, and the reason for each change. Around 16% of readmissions are due to medication nonadherence or errors. Most of these errors are preventable. 

Follow-up appointments. Detail appointments clearly, specifying the reason for each. In the observational study, half of the patients were not told why they needed a follow-up appointment — making it less likely they would prioritize it. 

Tests and results. Be sure patients know about any follow-up tests they need and why they are important. They should also be alerted of any pending results they should expect. 

Disease self-management. Help patients understand their responsibilities for ongoing care. Over half of the patients in the study were given no teaching on managing their disease. 

Red flags and warning signs. 82% of the patients studied were given no information on red-flag symptoms to watch for after discharge. Without this knowledge, patients can’t act quickly to get help when critical problems arise. 

Contact information. Write down the correct phone numbers patients can call for help after discharge. Cover which situations warrant a call to their doctor or surgeon, and which require emergency services. 

In addition to these topics, check that your patients will be able to follow the plan:

Assess barriers. Ask if there is anything that would prevent your patients from effectively managing their health, and help them overcome barriers. For example, providing medications with a meds-to-beds program can make a big difference for a patient who doesn’t have a ride to the pharmacy. 

Encourage questions. Check if anything is unclear. Ask if your patient has concerns about any part of the treatment plan. 

Orient to available resources. It may be that the only thing your patient remembers is where to look to find information. Show them your written education materials and emphasize their importance.

Patient Guide Solutions can help with well-designed, organized resources that make your information easy to access when your patient has questions later. 

Conclusion

By understanding how patients learn and applying that knowledge during discharge teaching — particularly on the morning of discharge — you can significantly enhance your patient education. Use desirable difficulty strategies and reinforce information with engaging, written resources to make learning stick. With these strategies, your patients will go home informed, confident, and prepared to care for themselves.