SHM Converge Scientific Abstract ePoster Gallery-From Readiness to Understanding: A Framework for Patient-Centered Discharge Education

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This project introduced a Complex Care Discharge Coordinator (CCDC) role in Memorial Hermann Hospital’s Medicine Service Line to improve discharge education for high-risk patients. The need arose because discharge teaching was often delayed until the day before or day of discharge, with no standard process to assess whether patients were ready to learn or truly understood instructions. This contributed to frequent post-discharge calls about home care.<br /><br />The CCDC supports six units and focuses on patients with complex discharge needs, such as wounds, drains, PEG tubes, PICCs, or tracheostomies. The coordinator assesses each patient’s cognitive status, learning needs, and preferred learning style, identifies the primary caregiver, and schedules education accordingly. Pre- and post-education surveys are used to measure understanding, with documentation entered into the electronic health record. If needed, additional teaching sessions and supplemental materials are provided. The nurse navigator and call-back coordinator also communicate daily with the CCDC to address patient and caregiver concerns.<br /><br />During the 5-month pilot, 283 encounters were documented, representing 193 unique patients and 198 teaching sessions. Forty-seven patients were readmitted within 30 days, for a 24.3% readmission rate. Only 12 patients completed satisfaction surveys, but feedback was mostly positive. Most notably, education-related callback volume dropped from an average of 8 calls per month before the pilot to fewer than 1 call per month, and this improvement continued for 12 months.<br /><br />Overall, the project showed that discharge education works best as a structured, patient-centered process that begins early, considers readiness and literacy, includes caregivers, and reinforces understanding to support safer transitions home.

Asset Subtitle

Andreea S. Xavier

Meta Tag

Author List Amee Amin, Andreea S. Xavier, Ben Clark, Elizabeth Mitchell, Jeffrey Chen, Rhonda Wade

Category Innovations

Concept Complex Care Discharge Coordinator

Concept Discharge Education

Concept Care Coordination

Concept High-Risk Patient

Concept Complex Discharge Needs

Distinguished Non-Finalist

Presenter Organization Memorial Hermann Texas Medical Center and UT Health Houston

Presenting Author Andreea S. Xavier

Track Transitions of Care

Keywords

Complex Care Discharge Coordinator

discharge education

high-risk patients

patient-centered care

caregiver involvement

readiness to learn

post-discharge calls

readmission rate

electronic health record

hospital discharge planning

Complex Care Discharge Coordinator

Discharge Education

Care Coordination

High-Risk Patient

Complex Discharge Needs