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Health Promotion Final Paper: Follow-up Care After Being Discharged

Athena Guzman

RN to BSN Nursing Program, Delaware Technical Community College

NUR 330-201: Population and Community Health

Mrs. Furlong

April 7, 2024
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Health Promotion Final Paper: Follow-Up Care After Being Discharged

My population/community will consist of the surgical community involving infants to the

elderly in Dover, DE. I will be informing on the healthcare needs for these patients in respect to

follow-up care after being discharged. The three main issues of concern with this community are

patient education and expectation setting; technology access & literacy, availability of resources

& support; misalignment of communication preferences. This is an important because regardless

of the surgical procedure the patient had, they will have follow-up instructions that will be

imperative for them to follow.

Review of the Data

Everyone getting their procedures done are always so anxious to get in and get out as

quickly as possible. I believe there is a lot of information that does get overlooked by patients,

caregivers, and sometimes staff. “Research shows that 32.9% of complications following general

surgery operations occur after discharge (Brajcich et al, 2021).” When patients are being

discharged, instructions are given to them and their caregiver. When information is not

understood properly and questions not asked, the patient has a potential to be readmitted to the

hospital or facility they are being discharged from. “Up to 20% of patients are readmitted within

30 days (IntellaTriage, 2018).” There is research that shows that because instructions differ from

different providers, and at times not written out toe a patient’s level of understanding, can cause

issues with understanding. “Up to half of the patients instructed to make the appointment may

not understand the reasons or mechanism for doing so, and therefore do not make the

appointment (Bajorek & McElroy, 2020).” If the patient does not get the follow-up appointment

made, the physician is not able to assess in a timely manner how the patient is recovery since

being home. Also, at the follow-up appointment is where the patient and the caregivers can talk
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about any concerns they may have since being home that may have believed was better to talk

about in person. Once we can get a hold of the barriers standing in the way of successful

discharges for patients, we can better educate decreasing the rates of complications and

readmissions.

Disparities and Barriers

The disparities that I have found to cause issues with discharging patients are patient

education & expectation setting, technology access & literacy, availability of resources &

support, and misalignment of communication preferences. “Transitions of care refer to the

movement of patients between different healthcare settings such as from an ambulance to the

emergency department, an intensive care unit to a medical ward, and the hospital to home

(Bajorek & McElroy, 2020).” Transitioning to different levels of care, and different facilities can

cause confusion if a patient and their caregiver do not understand everything that is going on.

When discussing patient education, it seemed as if the patients felt that they didn’t have

the necessary information prior to the surgery so they did not know what to expect for their post-

op. Those who had prior knowledge have a more positive outcome post discharge. “And having

that information prior to the surgery itself, I feel like, made me a more informed patient when I

was in the hospital (Brajcich et al, 2021).” When patients and their caregivers do not understand

what is going on, instead of asking for explainations they leave confused which means they will

not be able to correctly follow the post-op/discharge instructions that will tell them how to take

care of themselves and what medications they should be taken. “The current model relies on a

reactive approach, where patients must reach out to their clinical team with concerns, which may

result in treatment delays or unnecessary utilization of healthcare resources (Brajcich et al,

2021).”
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The healthcare system having moved primarily towards the tech savvy side causes issues

with those who are not as tech savvy. Many patients find it difficult to communicate if they can’t

call and directly speak to someone. They also feel that if they don’t directly speak to someone

their concerns won’t be heard and taken care of. “Discharge information should be written

clearly in patient-friendly terminology and be tailored to the patient’s learning style, social

determinants, and health literacy needs (Bajorek & McElroy, 2020).” Even if the discharge

instructions aren’t handwritten, there is the ability to make the instructions easy-to-read

instructions in different languages to better suit the patient and their caregiver. The goal is to

make sure they understand what they are reading so that they can care of themselves once they

leave the facility.

Many people don’t have reliable support to help them get to where they need to be when

they need to be there. They need to have someone who can listen to the instructions while also

remembering what they are being told so that they can help the patient once they are discharged.

“When patients get discharged after a hospital visit, it can be difficult for them to follow or

remember discharge instructions. This can lead to higher readmission rates, longer recovery

times and decreased patient satisfaction (IntellaTriage, 2018).” Many patients face different

challenges with having a reliable support system at home. Each patient needs at least one person

to rely on for their understanding of their discharge instructions. Many patients believe that

having someone to pick them up is enough not realizing that it isn’t enough when trying to make

sure they have the best set up possible when going home.

In this community some do have issues with transportation to and from which would

make it hard for them to get to their follow-up appointments. There are patients in the

community who are homeless, so when it comes time to be discharged, they do not have a place
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to go to, which means they didn’t necessarily always have insurance to pay for anything. When

patients have these issues, we know this at the beginning of their stay, and place consults with

care management and social work also gets involved. Patients can be offered a ride and a stay at

a shelter if the patient is agreeable to it. There is no guarantee that the patient will want to go to a

shelter, and there isn’t anything anyone can do about that. Those patients essentially aren’t able

and do not make it to any of their follow-up appointments. Those with no insurance in turn do

not even at times get themselves checked out due to knowing they would not be able to afford

what they need done. Information from the care managers and social workers can be given to

these patients to help assist them in getting help with medical insurance.

There are many ways to fix these disparities, but it requires work from everyone

involved. Coming up with plans to help with educating patients and their caregivers, making sure

to understand what issues stand in their way, and helping set up as much as you can for them

prior to them being discharged. Nurses are the ones to best help with the situations as they are the

ones giving them the discharge instructions and educating them on what they will need to

complete post discharge. The nurses will need to begin the discharge planning once the patients

are admitted or at the beginning of their surgical procedure. At that point they will be aware of

the barriers each patient faces prior to printing out the discharge instructions.

Develop 3 SMART Goals

The nurses are the front-line workers to be able to develop goals to help achieve success

in this area. First smart goal is to develop a plan to discuss with each patient and their caregiver

at the beginning of their admission day/surgical day what will be involved in their post-op

instructions. Second, will develop and lay out all the resources available to the patient and their

caregiver that is specific to each patient and their specific diagnosis. Lastly, during admission
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find out the best way to communicate with the patient and their caregiver prior to working on the

discharge instructions. All these goals are important as they will help provide a more optimal

experience for both the patient and the caregiver.

Role of the Nurse

The nurse’s role is to make their patients their number 1 priority. Educating their patients

from the minute that they meet them is important because that ensures that they will be ready

when it comes time to be discharged. It is imperative for the nurse to be well educated and

informed of the community that he/she is servicing. The more the nurse understands about that

specific community, the better he/she can educate the patient on their needs post discharge. A

nurse developing a plan that is patient specific means that it will only have information for that

patient to their specific needs. Everything will be tailored to what they had going on during their

procedure and what they will need to do afterwards. The plan will state when they need to make

their follow-up, what medications they will need to take, the diet they should follow, and the type

of activities they will be able to participate in. The nurse will be the best resource for the patient

and their caregiver. The nurse is the one who will take care of the patient and be able to put on

paper other resources that can be of assistance to the patient once they are home. When admitting

the patient, it is the nurse’s job to ask the correct questions to be able to identify the literacy level

of the patient, and any needs that the patient will have upon being discharged.

Interventions and Resources

Being able to come up with interventions and resources will show how helpful it will be

in optimizing the patient experience. The patient will need to identify during pre-op/admission

period what barriers they may face that could hinder their recovery process. Identifying the

barriers early on will help the nursing staff develop the correct plan specific for that patient. This
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means, if they know that the patient does not have a reliable support system at home with helping

set up appointments and get medications, care management can get involved and get medications

delivered to patients’ room if that is an option, and they can help set up the follow-up

appointment for the prior to them being discharged. The patient will need to be in agreeance with

the plan that is developed for them to ensure the benefits are truly met. Following the plan will

ensure that the patient understood what is expected of them once they are out of the hospital and

are home. Lastly, the patient will agree to reach out the resources given to them to help in their

needs after being discharged. This will include but are not limited to transportation services

(DART), getting help with medical insurance (Delaware Division of Social Services), and getting

help with paying for medications (Delaware Division of Social Services).

Health Promotion Plan

This plan will be essential to providing the necessary information for the patient to have a

successful recovery. Each plan will be vague and then customized to fit each patient and their

individual needs. The patient will need to go to the doctor’s office that has to deal with the

problem they are dealing with (ex: orthopedic doctor, ENT doctor, or podiatrist). Once the

patient gets seen, they will need to make sure they disclose all the problems they are having that

they need assistance with. The doctor will then decide the next steps for the patient like whether

they will need to have a surgical procedure. Once that is decided, they will set up and conduct all

the pre-operative testing, and procedures. This is when the patient can identify all the individual

needs and barriers that would make this procedure not be able to happen. What this means is that,

if the patient knows they will have a hard time making it to the surgery, or even to be able to

make it to any follow-up appointments, get any medications post-op or even knowing that they

will not have a good support system at home, the physician and staff can be aware and know how
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to proceed with the specific information. The patient will be told prior to their procedure if they

have insurance and how much the insurance agency will cover. If the patient does not have

insurance, they can talk with the physician to see what other options are available for them in

reference to the procedure they need. Once all the pre-operative steps are all completed the

patient will be scheduled for their surgical procedure. The patient would have been educated on

the process once the surgical procedure begins, and if there is a plan for an overnight stay. The

physician along with the nursing staff will have put together specific discharge instructions that

go to the patients’ individual needs. Before the patient gets discharged, they will be educated on

what is expected of them, and they will have plenty of opportunity to voice any concerns they

may have that they forget to ask prior to surgery, or that came to mind afterwards before they are

discharged. The patient will then agree to following everything set up for them in the plan that

was discussed, and they are discharged. The patient is then seen in one to two weeks post

procedure to discuss anything that have going on and see how well they are recovering. The

information for the resources of transportation in the community are as follows:

DART: Department of transportation in Dover, DE

900 Public Safety Blvd

Dover, DE 19901

(302) 739-3278

Delaware Division of Social Services

655 S Bay Rd

Dover, DE 19901

(302) 672-9500

Evaluation
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Making sure each patient had an optimal experience is a goal for the nurse who cared for

the patient. When doing follow-up care with the patient, it would be a smart move to check in

with the patient to see how the individualized plan worked for them. They can also give any

suggestions they feel could better help moving forward. Getting information from past patients

would be helpful to ensure there are not hiccups or issues next go around. I believe that if we as a

healthcare team can work on the known barriers that patients describe causes issues for them

when talking about follow-up care, we can make the necessary changes for them. Each patient

deserves the correct teachings and directions to better care for themselves post discharge. Our job

as nurses is to educate our community with the information that is best suited for them at the

present moment!
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References

Bajorek, S. A. & McElroy, V. March 25, 2020. Discharge Planning and Transitions of Care.

PSNet. https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care#

Brajcich, B.C., Shallcross, M.L., Johnson, J.K., Joung, R.H., Iroz, C.B., Holl, J.K., Bilimoria,

K.Y. & Merkow, R.P. July 23, 2021. Barriers to post-discharge monitoring and patient-

clinician communication. J Surg Res. Doi: 10.1016/j.jss.2021.06.032

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8822471/

September 12, 2018. Patient Engagement and Post Discharge Follow-Up. IntellaTriage.

https://intellatriage.com/blog/patient-engagement-strategies-for-post-discharge-follow-

up-care/