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The Aliki Initiative

 A Better Send-Off 
The Aliki team is making the discharge process more friendly  

  It's a milestone at once happy and uncertain: You've been in the hospital, and now it's time to leave - to go home, or perhaps to a rehab facility, or maybe even a nursing home.

Although it’s nice to be considered well enough to move on, many people leave the hospital with misgivings, usually after hours of "hurry up and wait," last-minute sign-offs from various doctors. If you’ve got family members with you, they may wonder if they should go ahead and grab some lunch – or dinner – while you just sit there, in that peculiar, last-day limbo.

" There’s such a rapid turnover that some patients will use the expression, ‘I was kicked out of the hospital.’ They feel like they were rushed out; very few people feel that the discharge process is planned in any way."

"I think everybody recognizes that the discharge process from all hospitals is dismal," says cardiologist Roy Ziegelstein, M.D. He is executive vice-chair of the Department of Medicine, deputy director for education, and co-director, with Cynthia Rand, M.D., of the Aliki Initiative (see side story), a groundbreaking program in patient-centered care for interns and residents. "There’s such a rapid turnover, in and out, that some patients will use the expression, ‘I was kicked out of the hospital.’ They feel like they were rushed out; very few people feel that the discharge process is planned in any way."

For doctors, nurses, and patients on the Aliki Service, the traditional, somewhat haphazard hospital discharge process is undergoing a huge makeover. With support from a challenge grant from the Picker Institute and Gold Foundation, two independent, nonprofit organizations dedicated to advancing patient-centered care, Aliki physicians are putting into place a new discharge curriculum, in which the patient becomes a vital part of the process. They believe ultimately, in addition to improving care, it will help reduce costs, lowering the rate of readmission by giving patients and their primary care physicians a better idea of what needs to happen after the hospital stay.

The plan will have several key features:

 Patient education. Right now, at hospitals worldwide, there’s not that much of this at discharge time, says Ziegelstein. "Even something simple – like when you bring your car to Jiffy Lube, and they go over what was done, what was not done, what you need done – nothing like that really happens." Patients, perhaps slightly overwhelmed by the process, or not functioning at top form because they’re still pretty sick, need some teaching when they’re about to go home – about their medications, for instance, or worrisome symptoms that mean they should call the doctor.      

 A moment to address any other concerns. Here’s a question that should be asked, and usually isn’t, says Ziegelstein. "‘Do you have any other concerns that we haven’t touched on here today?’ We never do that."

" I’m concerned because you want me to see my doctor in a week, but when I go home, I have to start taking care of my husband, who is much sicker than I am."

 The patient’s perspective. "The things that might concern the doctor or nurse are probably very important," Ziegelstein says, "like, ‘I’m concerned that your infection that seems to be getting much better might come back, so I’d like you to make sure to look at your leg every day, and if you see it start to get red again, or if it feels warm to the touch, please call me.’ But this kind of exchange seldom happens now in this country at the time of discharge." Worse, he adds, is that what almost never happens next is for the doctor to ask the patient to share any concerns that should be passed on to the primary care provider. This is unfortunate, because the patient’s next words might have been something like, "Yes, I’m concerned because I have no money to afford the antibiotics that you are prescribing so my leg won’t get red again," or "I’m concerned because you want me to see my doctor in a week, but when I go home, I have to start taking care of my husband, who is much sicker than I am, and I don’t know how I’m going to find the time to do the exercises that you want me to do, or return for my follow-up visit to my doctor."

With the Picker/Gold grant, Ziegelstein and Rand, with help from Aliki residents like Melissa Datallo, M.D., and from key Aliki faculty members including Janet Record, M.D., Laura Hanyok, M.D, and Colleen Christmas, M.D., have come up with key questions for the resident to ask the patient at the time of discharge.

"The patient and the resident are actually co-authoring the discharge form," says Rand. "And the form will certainly have our perspective – that is, ‘you were hospitalized for treatment of pneumonia, your medications at discharge are X and Y, we are asking you to take Z for five more days, and you have an appointment to see this doctor on Wednesday.’ But in addition, we will include, ‘We understand from talking to you that your concern is this, which will be communicated to your primary care physician. Here are some things you might be able to do, related to this concern.’ So the discharge form will always include the patient’s perspective."

The Aliki physicians are working with nursing leaders on the medical service to make sure that at the time of discharge, the doctor, nurse, and patient all meet face-to-face. "This may shock you; we’re hoping it can be done," says Ziegelstein. "We’re asking nurses, when they’re ready to do their discharge process, to page the intern," who will have 10 minutes to get to the patient’s room. "We are instructing them very specifically and deliberately about that. If they can’t go, we understand, because they may be tied up with an emergency, but then they have to page the resident to go in their place. And if the resident can’t go, we understand, everybody’s busy, but then they have to page the attending physician to go. So we’re really invested in making this work."

This is an opportunity, adds Rand, "for us to help patients have their questions answered, for families to better understand what took place, to better equip patients and families to take care of the illness when they get home. Our goal is to improve our patient- and family-centered practices, and this clearly has an impact on the patient’s overall well-being."

"I may be a Pollyanna," says Ziegelstein, "and this may be my view of Utopia, but I think this could be a big satisfier for everybody. I think everybody would agree that the patient would not get the feeling of being rushed out of the hospital if, in fact, there’s a conference that involves him or her, gets some dialogue going and hopefully some teaching from both the doctor and nurse. We’re really excited about this."