Audio Coursesby JellypodLesson 03 of 17
Overview
Vicky Muller: Alright, welcome back to Starting Strong. Today, we’re diving into one of the most critical—and honestly, nerve-wracking—parts of hospital medicine: transitions of care. I’m Vicky Muller, and I’m here with Beth Blimmer and Mark Krause. Let’s get right to it. When we talk about transitions of care, we mean those moments when a patient moves from one care setting to another—like from the hospital to home, or to a skilled nursing facility. These are high-risk periods for patient safety, and the numbers are, well, kind of alarming. Up to 49% of patients experience a medical error after discharge. That’s almost half. And what’s worse, a lot of these errors are preventable.
Beth Blimmer: Yeah, that stat always gets me. I mean, it’s wild to think that just moving a patient from one place to another can be so risky. And the most common errors? It’s usually medication discrepancies, unclear follow-up plans, or just plain bad communication. I remember as a resident, I’d get so anxious about making sure my discharge instructions were clear, but sometimes you just don’t know what you don’t know, right?
Mark Krause: Totally. And, you know, it’s not just about the paperwork. It’s about making sure the patient and their caregivers actually understand what’s supposed to happen next. I always say, if the patient can’t tell you their plan in their own words, you probably haven’t explained it well enough. Early mobilization, getting caregivers involved, and making sure discharge instructions are crystal clear—those are huge. Vicky, didn’t you have a story about a handoff that went sideways early in your career?
Vicky Muller: Oh, yeah. I’ll never forget it. I was a new attending, and I thought I’d done a decent job with a discharge, but I’d left the follow-up plan kind of vague. The patient ended up back in the ED two days later because no one knew who was supposed to check their labs. It was a wake-up call. Now, I always ask myself: Is this patient really ready for transition? And what makes discharge so risky is that you’re relying on so many moving parts—other providers, family, the patient’s own understanding. If any of those break down, things can go wrong fast.
Beth Blimmer: Exactly. And sometimes, even when you think you’ve covered everything, there’s a gap you didn’t see. That’s why I love using teach-back with patients—just having them repeat the plan back to me. It’s amazing what you catch that way.
Mark Krause: So, let’s talk about what actually works. From admission to discharge, there are some best practices that really make a difference. First, assess the home setup and support system right when the patient comes in. Don’t wait until the last minute. If they’re over 60, get PT or OT involved early. And, honestly, social work is your best friend for figuring out transportation or follow-up needs. I always forget the name of that cognitive screen—MoCA? Or is it KELS? Anyway, those are great for checking safety at home.
Vicky Muller: You’re right, Mark, and I’d add: start discharge planning on day one. Don’t wait until the day of discharge. Use plain language, get interpreters if you need them, and always write instructions in the patient’s first language if possible. And, please, emphasize medication changes. I can’t tell you how many times I’ve seen “resume home meds” written, and it’s just not enough. Involve caregivers, send the discharge summary and last hospital note, and always notify the next facility—call and fax, don’t just assume it’s handled.
Beth Blimmer: Yeah, and don’t forget about the pitfalls. Vague discharge summaries, missed calls to SNFs, last-minute med changes—those are the things that trip us up. I had a case where a 76-year-old was discharged to a SNF, but the nurse printed the original med list, not the updated one. The SNF got outdated info, and it could’ve led to a serious med error. It’s so easy for that to happen if you’re not double-checking communication.
Mark Krause: And, you know, when you’re looking for a new job, ask about the discharge process. Does social work or case management come to rounds? Is there a formal discharge planning process? Do they have post-discharge support, like follow-up clinics or care coordinators? Those are the things that make your life—and your patients’ lives—a lot easier. Oh, and be proactive with follow-up plans. If you know a patient needs labs or wound checks, set it up before they leave. Don’t just hope someone else will do it.
Beth Blimmer: I love that. And honestly, teach-back has saved me so many times. I’ll have patients or families repeat the plan, and sometimes they’ll say something totally different than what I thought I explained. It’s humbling, but it’s better to catch it before they go home.
Vicky Muller: So, how do we make these transitions safer, not just for one patient, but across the board? Standardized discharge checklists are a game changer. They make sure you don’t miss the basics—medication reconciliation, follow-up appointments, patient education. It’s about consistency, so every provider is on the same page.
Mark Krause: Yeah, and don’t underestimate the power of a good team meeting. For complex cases, get everyone together before discharge—nursing, pharmacy, social work, therapy. It’s like, if you’re all in the same room, you can spot those communication gaps before they become real problems. I mean, sometimes you find out the patient’s ride home fell through, or the wound care plan isn’t clear, and you can fix it right then.
Beth Blimmer: And patient-centered education is huge. I use teach-back, but also visual aids—like, literally drawing out the med schedule or using pictures. Some patients just need to see it, not just hear it. And if you can get the caregiver involved, even better. I always say, if the family can explain the plan, you’re in good shape.
Vicky Muller: Exactly. And don’t forget, written and verbal communication both matter. Some patients need to read it, some need to hear it, and some need both. The more ways you can reinforce the plan, the better the chance they’ll actually follow it. And, honestly, it’s not just about avoiding readmissions—it’s about making sure patients feel supported and safe when they leave us.
Mark Krause: Alright, let’s get into some real-life cases. First up, the 65-year-old with CHF who was discharged to a SNF after AKI. Diuretics were held, but the discharge summary didn’t say why or who should restart them. That’s a recipe for confusion. If you don’t clarify who’s responsible—SNF doc, PCP, whoever—things can fall through the cracks. I mean, I’ve seen this happen, and it’s not pretty.
Beth Blimmer: Yeah, and then there’s the 59-year-old with mild cognitive impairment on warfarin. They come back with an INR over 6 and bleeding, and no one knows who was supposed to be monitoring it. The family’s lost, the patient’s lost, and you’re left wondering, “Did we set them up to fail?” It’s heartbreaking, but it’s also preventable if you ask the right questions at discharge—like, do they have home INR monitoring? Can they get to the lab? Is there a caregiver who understands what to do?
Vicky Muller: And that’s why early planning is so important. Get social work and case management involved from the start, not just at the end. Make sure both written and verbal instructions are clear, and document everything. Someone else is going to be reading your notes, so make it easy for them to follow the plan. Mark, didn’t you have a story about tracking down a warfarin patient’s follow-up?
Mark Krause: Oh, yeah. I called it the “warfarin treasure hunt.” I had a patient who was supposed to get their INR checked, but no one knew where or when. I ended up calling three different clinics, the family, and even the neighbor’s dog—okay, not really the dog, but it felt like it. Eventually, we found out the patient thought the “INR” was a new TV channel. It was funny, but also a reminder that if you don’t spell things out, people get lost. So, always clarify who’s doing what, and don’t assume anything.
Beth Blimmer: That’s such a good point. And honestly, these cases just show how important it is to start planning early, involve the whole team, and make your documentation clear. It’s not just about checking boxes—it’s about making sure the patient actually gets the care they need after they leave us.
Vicky Muller: Absolutely. So, to wrap up, start discharge planning on admission, engage your team early, focus on communication, and always document your plan clearly. Thanks for joining us for this episode of Starting Strong. Beth, Mark, always a pleasure.
Beth Blimmer: Thanks, Vicky! This was great. Mark, see you next time?
Mark Krause: Wouldn’t miss it. Thanks, everyone, and take care out there.
