SHM Converge Scientific Abstract ePoster Gallery-Transitions of Care: Timing of Discharge Notice

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Hospitals must provide Medicare inpatients hospitalized more than two days with the “Important Message from Medicare” (IMM) at least four hours before discharge. This project evaluated whether giving patients earlier notice of planned discharge through an existing EMR process would improve outcomes.<br /><br />In November 2024, hospitalist teams were coached to notify patients or caregivers 24–48 hours before discharge, then place an “Implement DC Plan” (IDP) order in the EMR. Nurses used this order to deliver the IMM form or contact caregivers by phone if the patient lacked capacity. The process applied to Medicare and non-Medicare patients, and compliance was audited.<br /><br />The analysis included patients with lengths of stay from 3 to 30 days who were discharged home, with or without home services. Compared with 2024, IDP use increased significantly in 2025 from 78% to 90%. Timing also improved: one-day advance notice rose from 43.6% to 49.8%, two-day notice from 14.2% to 16.3%, while same-day notice fell from 35.1% to 28.9%.<br /><br />However, combining 2024 and 2025 data showed no meaningful difference in readmission rates or length of stay between patients who received same-day/no notice and those who received 1–2 days of advance notice. Readmission rates were similar across groups, and average length of stay did not improve with earlier notice.<br /><br />Overall, the study found that improving the timing of discharge notice increased compliance with discharge planning processes, but did not reduce readmissions or shorten hospital stay. The authors suggest next steps should include surveying nurses, social workers, and patients to identify better ways to communicate discharge timing and improve care transitions.

Asset Subtitle

Kathy F. Navid

Meta Tag

Author List Kathy F. Navid

Category Research

Concept Medicare Important Message

Concept Discharge Planning Order

Concept Advance Discharge Notice

Concept Discharge Appeal Notification

Concept Readmission Rate

Distinguished Non-Finalist

Presenter Organization Mount Sinai Queens

Presenting Author Kathy F. Navid

Track Transitions of Care

Keywords

Medicare

Important Message from Medicare

discharge planning

hospital discharge

EMR process

advance notice

readmission rates

length of stay

hospitalist teams

care transitions

Medicare Important Message

Discharge Planning Order

Advance Discharge Notice

Discharge Appeal Notification

Readmission Rate