Improving Transition of Care: Supporting Patients After Hospital Discharge

Ruscilli, Chloe

Item

Improving Transition of Care: Supporting Patients After Hospital Discharge

Ruscilli, Chloe

License

http://creativecommons.org/licenses/by/4.0/

Abstract

Background/Purpose: Timely follow-up after hospital discharge is critical for patient outcomes, particularly among vulnerable populations, including Black, Hispanic, Medicaid, and low-SES patients. Many patients struggle to recall discharge instructions, and routine practices often lack clear guidance. At Newtown Primary Care, patients reported confusion about follow-up appointments, medication changes, and diagnoses. This project aimed to develop a simple, patient-centered handout to improve understanding and continuity of care. Methods: Patients, family members, and primary care providers reviewed a structured discharge handout featuring organized instructions and medication instruction. Feedback on clarity, usability, and completeness was collected to assess its effectiveness in supporting post-hospital care. Results: The handout was well-received. Patients and family members reported improved understanding and easier navigation of discharge instructions. Providers noted enhanced comprehension, particularly when complex conditions or multiple medications were involved. Conclusion/Implications: Structured, patient-centered discharge materials can improve understanding and continuity of care. Expanding this approach to other hospital departments and tracking follow-up adherence could reduce preventable readmissions and associated healthcare costs.