From the University of Utah College of Nursing, Salt Lake City, UT (CEE, ME, KES, AAB, ASW); University of Utah School of Medicine, Salt Lake City, UT (SER, EPJ, MBC).
J Am Board Fam Med. 2024 Jul-Aug;37(4):706-736. doi: 10.3122/jabfm.2023.230172R3.
Discharge communication between hospitalists and primary care clinicians is essential to improve care coordination, minimize adverse events, and decrease unplanned health services use. Health-related social needs are key drivers of health, and hospitalists and primary care clinicians value communicating social needs at discharge.
To 1) characterize the current state of discharge communications between an academic medical center hospital and primary care clinicians at associated clinics; 2) seek feedback about the potential usefulness of discharge readiness information to primary care clinicians.
Exploratory, convergent mixed methods.
Primary care clinicians from Family Medicine and General Internal Medicine of an academic medical center in the US Intermountain West.
Literature-informed REDCap survey. Semistructured interview guide developed with key informants, grounded in current literature. Survey data were descriptively summarized; interview data were deductively and inductively coded, organized by topics.
Two key topics emerged: 1) discharge communication, with interrelated topics of transitional care management and follow-up appointment challenges, and recommendations for improving discharge communication; and 2) usefulness of the discharge readiness information, included interrelated topics related to lack of shared understanding about roles and responsibilities across settings and ethical concerns related to identifying problems that may not have solutions.
While reiterating perennial discharge communication and transitional care management challenges, this study reveals new evidence about how these issues are interrelated with assessing and responding to patients' lack of readiness for discharge and unmet social needs during care transitions. Primary care clinicians had mixed views on the usefulness of discharge readiness information. We offer recommendations for improving discharge communication and transitional care management (TCM) processes, which may be applicable in other care settings.
医院医生与初级保健临床医生之间的出院沟通对于改善护理协调、最大限度地减少不良事件和减少非计划卫生服务的使用至关重要。与健康相关的社会需求是健康的关键驱动因素，医院医生和初级保健临床医生重视在出院时沟通社会需求。
1）描述学术医疗中心医院与相关诊所的初级保健临床医生之间目前的出院沟通情况；2）寻求关于初级保健临床医生对出院准备信息潜在有用性的反馈。
探索性、收敛性混合方法。
美国山间西部一所学术医疗中心的家庭医学和普通内科的初级保健临床医生。
受文献启发的 REDCap 调查。与主要知情人共同制定的半结构化访谈指南，以当前文献为基础。对调查数据进行描述性总结；对访谈数据进行演绎和归纳编码，按照主题组织。
出现了两个主要主题：1）出院沟通，与过渡性护理管理和后续预约挑战等相关主题，以及改善出院沟通的建议；2）出院准备信息的有用性，包括与跨环境角色和责任缺乏共同理解以及与识别可能没有解决方案的问题相关的道德关注相关的主题。
虽然重申了长期存在的出院沟通和过渡性护理管理挑战，但本研究揭示了新的证据，表明这些问题如何与评估和应对患者出院准备不足和过渡期间未满足的社会需求相互关联。初级保健临床医生对出院准备信息的有用性看法不一。我们提出了改进出院沟通和过渡性护理管理（TCM）流程的建议，这些建议可能适用于其他护理环境。
