Poor discharge practices can result in poor patient experience, silloed care and adverse events such as avoidable emergency room visits and readmissions to hospital.  A key factor is poor communication and non-comprehension of discharge instructions.  The Patient-Oriented Discharge Summary (PODS) is a discharge instruction tool co-designed with patients and family caregivers as an adaptable written template containing key information for providers and patients to use at time of discharge.  Our project evaluated the impact of PODS across 5 acute care and rehabilitation hospitals in Ontario on patient experience and receipt of key instructions linked to high quality care along with health-care utilization.  This project’s early findings helped refine the tool and methodology as well as secure funding for the spread of PODS across more than 30 hospitals in Ontario. PODS is now recognized in Ontario Health’s Quality Standards for Care Transitions and continues to spread throughout Canada as a key component of high quality discharge and new integrated care models.

The period following discharge from hospital is a vulnerable time for patients. Poor discharge practices can result in adverse events such as avoidable emergency room visits and hospital readmissions. A key causal factor is poor communication and non-comprehension of discharge instructions. Our innovation is a novel written discharge instruction tool (PODS) which replaces traditional non-standardized and/or verbal instructions.  We hypothesized PODS would help health care providers use standardized patient-centered instructions to engage with patients and families at time of discharge.  Following successful early feasibility and usability, our randomized controlled trial evaluated how PODS improved patient experience and receipt of key instructions, along with scheduled and unscheduled visits to primary care and emergency departments.  Of the 493 individuals randomized (249 PODS/ 244 usual care), the rate of events (negative responses to patient experiences) were identifical in both groups (RR = 0.95, 95% CI 0.78-1.16) with a low but similar mean number of negative reponses between both groups (1.34 +/-1.38 usual care vs. 1.28 +/- 1.34 in PODS).  Subgroup analyses suggested however that PODS impact may have differed among hospitals and that subgroups with low income reported understanding their medications more than those of higher income.  Interviews with staff, patients and families suggested differing practices across sites and behavior change by healthcare providers, including with patients in the control group, may have contributed to the lack of demonstrable quantitative impact.  Our qualitative findings suggest that a patient-centred framework that promotes relationships with a patient’s primary care provider, previous experiences with discharge, addresses equity barriers such as income disparities, and enhances patient and caregiver engagement at the time of discharge may optimize patient experience, receipt and understanding of discharge instructions.

Hahn-Goldberg S, Jeffs L, Troup A, Kubba R, Okrainec K.  “We are doing it together”; The integral role of caregivers in a patients’ transition home from the medicine unit.  Plos One 2018; 13: e0197831. https://doi.org/10.1371/journal.pone.0197831

Schofield T, Bhatia RS, Yin C, Hahn-Goldberg S, Okrainec K. Patient experiences using a novel tool to improve care transitions in patients with heart failure: a qualitative analysis. BMJ Open 2019;9:e026822. doi:10.1136/ bmjopen-2018-026822

Saragosa M, Jeffs L, Hahn-Goldberg S, Abrams H, Soong C, Hart M et al.  “There was no preamble”: Comparing the Transition from Hospital to Home in Different Care Settings. Canadian Journal on Aging 2020; 40: 282-292. DOI: 10.1017/s0714980820000380

Sachdeva M, Troup A, Jeffs L, Matelski J, Bell CM, Okrainec K.  “I Had Bills to Pay”: A Mixed-Methods Study on the Role of Income on Care Transitions in a Public-Payer Healthcare System.  J Gen Intern Med 2023; 38: 1606-1614. https://doi.org/10.1007/s11606-023-08024-7

Griffiths S, Stephen G, Kiran T, Okrainec K. “She knows me best”: a qualitative study of patient and caregiver views on the role of the primary care physician follow-up post-hospital discharge in individuals admitted with chronic obstructive pulmonary disease or congestive heart failure. BMC Fam Pract. 2021 Sep 7;22(1):176. doi: 10.1186/s12875-021-01524-7.