SHM Converge Scientific Abstract ePoster Gallery-Care Beyond the Hospital, Start Strong Finish Strong. Multidisciplinary Team to Improve Transition of Care

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This project addressed the vulnerability of hospital discharge, especially for patients with limited health literacy and language barriers. The team at Lincoln Medical Center implemented a standardized, multidisciplinary discharge workflow involving physicians, nurses, pharmacists, clerical staff, and interpreters to improve transitions of care.<br /><br />The intervention included a structured discharge script covering the reason for admission, medications, and follow-up appointments. Physicians coordinated discharge timing with nurses so both could review the care plan together at the bedside. Education emphasized each medication’s purpose and dosing, and certified interpreters were used for non-English-speaking patients. Patients and families were encouraged to repeat instructions in their own words to confirm understanding. Medication bags were provided to help organize prescriptions, clerical staff ensured accurate contact information and scheduled follow-up appointments before discharge, and assigned staff made 72-hour post-discharge calls to assess understanding, satisfaction, and barriers. The process was reinforced through monthly resident education and a training video for new staff.<br /><br />After three months, post-discharge calls showed improvement in patient understanding and experience. In 97% of cases, the care team used the patient’s preferred language, and 94% of patients reported understanding their discharge instructions. In 75% of discharges, both physician and nurse participated together. Ninety percent of respondents could identify warning symptoms, and medication education improved, with better communication about medication indications and side effects. Overall understanding of health improved from 32% to 47.8%.<br /><br />The authors concluded that a structured, multilingual, team-based discharge process improves patient comprehension, satisfaction, and preparedness for home, helping patients take a more active role in their ongoing care.

Asset Subtitle

Ibtihal Safih

Meta Tag

Author List Adarlyn Guzman, Alaa Bahr, Ariane Yangco, David R. Serrano, Elissa (Tam) Suris, Ibtihal Safih, Jharna Bai, Marcos Borthelle, Reejen Monsalve Coz, Vidya Menon, Wajiha Ahmed, Ye Aung, Yula Danova

Category Research

Concept Discharge Workflow

Concept Transitional Care

Concept Patient Preparedness for Discharge

Concept Multidisciplinary Team

Concept Medication

Distinguished Non-Finalist

Presenter Organization NYCHHC/lincoln Hospital

Presenting Author Ibtihal Safih

Track Transitions of Care

Keywords

hospital discharge

health literacy

language barriers

multidisciplinary workflow

transitions of care

patient education

interpreter services

medication counseling

follow-up appointments

patient comprehension

Discharge Workflow

Transitional Care

Patient Preparedness for Discharge

Multidisciplinary Team

Medication