Discharge Counseling Guide

Introduction to Discharge Counseling

  • Overview of discharge counseling in the inpatient setting.

  • Similarities to traditional patient education.

  • Importance of transitions of care when patients are released from the hospital.

Importance of Discharge Counseling

  • Transitions of Care: Critical step to prevent medical errors as patients move from hospital to home or another care facility.

    • Common Issues:

    • Medication errors (wrong doses, omissions, duplications).

    • Patients may continue unnecessary medications or discontinue needed ones.

    • Risk of being confused with formulary substitutions (e.g., two different statins).

  • Medication Management:

    • Ensure correct understanding and adherence to medication regimens, covering:

    • How to take medications (with food, using devices).

    • Storage requirements.

    • Anticipated effects and onset time.

  • Adherence Issues: Assessing barriers (e.g., mail order medications vs. local pharmacy).

Goals of Counseling

  • Twofold Approach:

    1. Counseling on medications.

    2. General patient education related to their case.

  • Components Involved:

    • New medications and immunizations; traditional counseling approach required.

    • Ongoing medications with no changes; require reassessment.

    • Changes in medications and any discontinued medications; require medication reconciliation.

Medication Reconciliation Process

  • Collection of Information:

    • Review all medications:

    • Prior to admission (PTA) meds.

    • Medications started during hospitalization.

    • Medications prescribed at discharge.

  • Assessment of Issues:

    • Identify any discrepancies such as duplications or omissions before counseling.

    • Ensure that interventions (if any) are communicated back to the prescriber before talking to the patient.

Communication with Providers

  • Address any identified discrepancies with the prescriber before discussing with the patient.

  • Patient Interactions:

    • If a medication is problematic (e.g., transportation for infusions is not available), inform the patient of how you will address this with the prescriber.

Counseling Steps for Patients

  • Documentation Process:

    • Document counseling action in pharmacy programming or consult notes as necessary.

  • Written and Verbal Instructions:

    • Evidence shows combining verbal with written instructions enhances patient understanding and adherence.

    • Use worksheets to organize and present information clearly.

Standard vs. Discharge Counseling

  • Prime Questions: Always organize counseling into three main components.

  • Changes in Structure:

    • New medication counseling.

    • Continuing medications (akin to refills).

    • Changed medications.

  • Subtle Differences:

    • Patients may need to dispose of old medications when receiving new prescriptions.

Prime Questions for Counseling

  1. What Did Your Doctor Tell You About This?

    • Explain the medication's purpose, side effects, and efficacy expectations.

    • Discuss preventive measures (e.g., signs of stroke prevention).

  2. How Did Your Doctor Tell You to Take This?

    • Address administration methods (e.g., device instructions).

  3. What Did Your Doctor Tell You to Expect?

    • Define when to expect medication effects and potential side effects.

For Continued Medications

  • Similar to Refills:

    • Verify how patients have been taking their ongoing medications.

    • Confirm continued access to medications and any barriers.

For Changed Medications

  • Tailored Questions:

  1. Do You Know What You're Taking This Medication For?

    • Confirm understanding of the changed regimen.

  2. What Did the Prescriber Tell You About Your Changes?

    • Clarify instructions and regimens.

  3. What Did the Doctor Tell You to Expect with These Changes?

    • Discuss potential side effects related to dosage changes.

Teach-Back Method

  • Key Information is crucial:

    • Focus teaching back on new or corrected information.

    • Utilize prime questions for clarity of understanding.

  • Excellent way to assess comprehension, especially for numerous medications.

Preparing for Discharge Counseling

  • Chart Review:

    • Read discharge summary and recent progress notes to understand:

      • Patient's case history.

      • Medications transitioning to home.

  • Medication Reconciliation:

    • Compare home medications, hospital medications, and discharge medications.

    • Identify what to counsel on.

  • Use of Written Instructions:

    • Prepare written guidelines to use alongside verbal instructions.

  • Time Management:

    • Aim for 10-15 minutes for patient counseling in practice settings.

Using Worksheets for Counseling

  • Structure of Worksheet:

    • Organize by medical condition rather than by medication for clarity.

    • Include a comments section for medication changes/discontinuation, ADE (adverse drug events).

    • Provide a weekly pillbox format on the reverse side for medication scheduling.

Final Considerations

  • Always ensure patients understand how to manage their medications post-discharge, emphasizing steps for disposal and adherence strategies.

  • Continuous patient communication post-counseling is crucial to follow up on adherence and any problems encountered.

  • Ensure familiarity with the worksheet for effective communication in real-life situations.