PDTK

Patient-Centered Discharge Toolkit

The Patient-Centered Discharge Toolkit identifies discharge barriers for individual patients. Care teams can address these barriers and prepare patients for a smooth transition from hospitalization to post-discharge care at home.

Background & Goals

PDTK was a 4th sub-project developed under PSLL 1.0. Once a hospitalized patient’s expected discharge date is set, the Patient-Centered Discharge Toolkit encourages providers to engage the patient in discharge preparation using a checklist. This tool aims to identify discharge barriers for individual patients so that their care teams can proactively address them and prepare them for discharge. PDTK leverages already established PSLL HIT infrastructure (patient portal, dashboard, secure messaging) in order to facilitate patient-provider communication.

Results

Patients and care partners can access the Pre-Discharge Checklist using the Patient Portal or independently using REDCap, either delivered to patients’ mobile device, or completed on a tablet in collaboration with trained staff (RA).

Pre-Discharge Checklist (REDCap)

Pre-Discharge Checklist (Patient Portal)

The discharge checklist contains a variety of questions to gauge patients’ understanding of post-discharge care plan and self-care management.

A discharge column was added to the Patient Safety Dashboard to account for patient discharge preparedness. Upon pre-discharge checklist submission, a checklist icon is triggered in the dashboard. The patient-reported data is available in the EHR in real-time.

Patient Safety Dashboard: Discharge Column

Providers can review the checklist in the safety dashboard.

At discharge, a secure messaging thread (Imprivata) is initiated to facilitate patient-provider communication.

Patient-Provider Messaging Thread

Ultimately, the Patient-Centered Discharge Toolkit prepares patients to transition from hospitalization to post-discharge care at home.