Transitions for High-Risk Patients — Discharge Bundle Template

Purpose and Scope

This playbook provides a modular discharge bundle for patients at high risk of poor outcomes after discharge — including those with complex clinical conditions, multiple medications, behavioral health needs, unstable housing, limited social supports, or limited health literacy. The bundle standardizes key actions, assigns roles, and offers templates to reduce readmissions, medication harm, and fragmentation of care.

When to Apply this Bundle (Triggers)

• Age > 65 with 3+ chronic conditions and 5+ medications
• Recent prior admission(s) within 30 days
• New or changed high-risk medication (anticoagulant, insulin, opioids)
• Identified social risk (unstable housing, food insecurity, limited caregiver support)
• Behavioral health concerns that affect follow-up or adherence

Bundle Modules — What to Do, Who, and When

1. Medication reconciliation + teach-back

   What: Complete reconciled medication list in the chart, pharmacy reconciliation if possible, medicines dispensed or prescriptions given, and a patient-facing medication list.

   How: Pharmacist or trained nurse performs reconciliation with the patient/caregiver before discharge, documents discrepancies and actions, and uses the teach-back method to confirm understanding.

   Outputs: Reconciled med list uploaded to EHR, printed med card or SMS/portal copy, documented teach-back note.

   Timing: Within 24 hours before discharge or at bedside at discharge.

2. Timely follow-up appointment scheduling

   What: Date/time for primary care or specialist follow-up scheduled prior to discharge (target within 7 days for highest-risk patients).

   How: Discharge coordinator schedules appointment before the patient leaves. Include transportation and telehealth options, and confirm the clinic accepts any relevant payer or referral.

   Outputs: Appointment details provided on discharge instructions and entered into EHR and patient reminder system.

   Timing: Before discharge.

3. Post-discharge check-in call: script and timing

   What: A structured outreach call or telehealth check within 48–72 hours post-discharge, with a follow-up at 7–14 days as indicated.

   How: Care navigator, nurse, or case manager uses a brief validated script to check meds, symptoms, appointments, equipment needs, and social supports. Document call outcome and escalate unresolved issues.

   Sample script: "Hi, I’m calling from [Hospital/Clinic]. I’m checking on how you're doing since you left on [date]. Are you taking your medicines as listed? Do you understand each medicine’s purpose? Have you been to your follow-up appointment or need help getting there? Are you able to get food, heat, and a safe place to stay?"

   Outputs: Call log with disposition (OK, needs pharmacy, needs transport, urgent clinic visit, ED), and assigned follow-up task.

   Timing: First call within 48–72 hours; additional calls based on risk.

4. Social needs screening and referral plan

   What: Short screening for housing, food security, transportation, utilities, caregiver capacity, legal needs, and safety.

   How: Social worker or navigator administers a structured screening (2–6 questions) before discharge and initiates referrals (community organizations, benefits enrollment, home health, durable medical equipment, respite, or crisis services).

   Outputs: Documented screening results, referrals placed, and expected next steps for the patient/caregiver.

   Timing: During discharge planning; referrals completed before or immediately after discharge.

5. Care plan summary and patient/caregiver education

   What: Clear, plain-language discharge instructions that summarize diagnosis, warning signs, when to seek care, follow-up plan, and contact numbers.

   How: Use teach-back to confirm understanding; provide printed and electronic copies; include a prioritized short checklist of what to do first 48–72 hours after discharge.

Roles and Responsibilities

• Discharging clinician: Confirms medical stability and communicates key follow-up needs.
• Pharmacist or medication reconciliation lead: Performs reconciliation and documents teach-back.
• Discharge coordinator / case manager: Schedules follow-up, coordinates referrals, ensures transport and home services.
• Social worker / navigator: Performs social needs screening and referral.
• Care navigator or nurse: Conducts post-discharge calls and documents outcomes.

Measurement — Definitions and How to Use Them

Use consistent definitions so teams can track improvement and compare progress.

• 7-day readmission rate: Number of patients in the bundle readmitted within 7 days / total bundle discharges. Source: EHR admission logs.
• 30-day readmission rate: Number readmitted within 30 days / total bundle discharges.
• Follow-up visit adherence: Percent of patients with scheduled follow-up completed within target window (e.g., 7 days) / total with scheduled follow-up.
• Medication discrepancies found post-discharge: Count of discrepancies identified during post-discharge reconciliation calls per 100 discharges.
• Post-discharge call success rate: Percent of patients successfully reached within 72 hours.

Recommended frequency: Weekly for operational monitoring during pilot, monthly for leadership reporting. Set pragmatic targets (e.g., 7-day readmissions < baseline by X%).

Sample Tools & Templates

Medication Reconciliation Checklist (brief)

• Confirm current home medication list with patient/caregiver
• Compare with inpatient medication orders and discharge prescriptions
• Identify discrepancies and resolve (documented)
• Provide patient-friendly med list and review via teach-back

Post-discharge Call Script (short)

Intro: "Hello, this is [name] from [hospital]. I'm checking how you're doing after your discharge on [date]."

1. Are you taking your medicines? Any questions or side effects?
2. Do you have your follow-up appointment on [date/time]?
3. Do you have food, transportation, and a safe place to recover?
4. Do you feel worse, or have new or worsening symptoms?

Disposition codes: No issues / Needs pharmacy / Needs transport / Needs urgent clinic / Recommend ED — then record action.

Implementation Checklist (Pilot)

1. Assemble multidisciplinary pilot team (medicine, pharmacy, nursing, social work, IT).
2. Agree on high-risk triggers and inclusion criteria.
3. Map current discharge workflow and insert bundle steps.
4. Create EHR fields/templates or paper forms for med reconciliation, teach-back, follow-up scheduling, and post-discharge call documentation.
5. Train staff on teach-back, brief screening, and call scripts.
6. Run a 4–8 week pilot on a ward or service, collect measures weekly, and iterate.
7. Scale once stable, with local tailoring and governance owner assigned.

Tailoring Guidance

Keep core elements (med reconciliation, timely follow-up, early outreach, social needs screening). Tailor timing windows, follow-up targets, and referral partners to local resources. Document any local deviations and rationale so outcomes remain comparable.

Digital & Data Opportunities (Suggested)

Converting checklists and call scripts into small interactive forms makes consistent documentation and measurement easier. Use an electronic discharge checklist that captures trigger criteria, reconciliation status, appointment details, and call dispositions. Captured data can feed local dashboards and improvement cycles.

Suggested next steps: create an interactive discharge checklist form, a post-discharge call logging form, and standard data exports for readmission and follow-up adherence monitoring.

Safety & Equity Considerations

Ensure materials are available in the patient’s preferred language and accessible formats. Screen for and address social needs equitably. Track outcomes by race, language, and payer to surface disparities.

Governance and Ownership

Assign a clinical owner (e.g., Director of Care Transitions) and an operational lead (nurse manager or quality improvement lead). Review bundle performance monthly and refresh protocols annually or after major workflow changes.

References & Evidence

Adapt local references and guidelines (national care transition programs, medication safety guidance, community resource directories). Cite pertinent local protocols when tailoring.

Quick Start: Three Immediate Actions

1. Identify a pilot team and one clinical unit to test the bundle for 4–8 weeks.
2. Create a simple med reconciliation + teach-back form and ensure pharmacy involvement for that pilot.
3. Start the 48–72 hour post-discharge call process and record dispositions for immediate feedback.