Maya Peters is a research associate with MVC.

Members of the Care Transitions team at St. Mary Mercy Livonia recently shared with MVC an innovative effort to improve the discharge process at their hospital, which resulted in increases in the HCAHP scores for both Patient Satisfaction and Transitions of Care. I had the privilege of speaking with Catherine Ponder, RN, BSN, and Sue Klotz, MS, BSN, RN-BC, both of whom were integral in the development and implementation of a concise, organized system to manage the personalized information each patient receives throughout their hospital stay.  

An unorganized discharge process leads not only to confusion, but can contribute to future readmissions due to medical discrepancies, unscheduled follow-up appointments and a lack of education on disease symptoms. Catherine and Sue’s team realized many patients struggle to keep all of the information received at the hospital straight after being discharged, and often feel overwhelmed once they’re back at home. 

To help address the disjointed nature of the acute to post-acute transition, the care transitions team, along with input from frontline RNs and the Patient Family Advisory Council, created a three pocket folder that each patient receives upon admission to the hospital. This folder follows each patient throughout their hospital stay and extends into the home. The contents of the folder include: name and number of the patient’s primary doctor and follow-up appointment; discharge information, including symptoms and the patient’s health problems; medications, prescriptions, and side-effects; education materials, advanced directives, goals of care; and finally, questions the patient has for their doctor. The folder is introduced to the patient upon admission.  A nurse helps patients to fill out the “Questions for my doctor” section, and other medical professionals visiting the patient may add relevant materials to the folder as needed.  The day following discharge, each patient receives a follow-up phone call.

Initially conceived in 2012, the folder has undergone a number of iterations and revisions. The Marketing team helped make the folder as usable as possible for seniors by increasing the font size, adding icons and using concise language.  According to Catherine and Sue, the key to making the discharge folder initiative and implementation successful was the involvement, assistance and engagement of the nurse practice council who were actively involved and provide ongoing feedback.

Since the roll-out of the new discharge process in summer 2015, Catherine and Sue have seen positive results in supporting patient engagement.  More importantly, one of the most rewarding aspects of the program is seeing patients’ confidence increase.  The folder allows patients to feel more capable of managing their health and discussing their needs with medical professionals.


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