FACILITATING PATIENT
UNDERSTANDING OF
DISCHARGE INSTRUCTIONS
WORKSHOP SUMMARY
Joe Alper and Lyla M. Hernandez, Rapporteurs
Roundtable on Health Literacy
Board on Population Health and Public Health Practice
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The workshop that is the subject of this workshop summary was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
This activity was supported by contracts between the National Academy of Sciences and the Agency for Healthcare Research and Quality (HHSP233200900537P); California Dental Association; East Bay Community Foundation (Kaiser Permanente); Eli Lilly and Company; Health Resources and Services Administration (HHSH25034004T); Humana; Johnson & Johnson; Merck and Co., Inc.; Office of Disease Prevention and Health Promotion; and UnitedHealth Group. The views presented in this publication are those of the rapporteur and do not necessarily reflect the views of the organizations or agencies that provided support for the activity.
International Standard Book Number-13: 978-0-309-30738-3
International Standard Book Number-10: 0-309-30738-4
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Suggested citation: IOM (Institute of Medicine). 2014. Facilitating patient understanding of discharge instructions: Workshop summary. Washington, DC: The National Academies Press.
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Victor J. Dzau is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council.
PLANNING COMMITTEE ON IMPLICATIONS OF HEALTH LITERACY FOR DISCHARGE INSTRUCTIONS1
DARREN DEWALT, Associate Professor of Medicine, University of North Carolina at Chapel Hill
BENARD DREYER, Professor of Pediatrics, New York University School of Medicine
ALEX FEDERMAN, Associate Professor of Medicine, Mount Sinai Hospital
GEORGE ISHAM, Senior Advisor, HealthPartners, Senior Fellow, HealthPartners Institute for Education and Research
RUTH PARKER, Professor of Medicine, Pediatrics, and Public Health, Emory University School of Medicine
_______________
1Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution.
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ROUNDTABLE ON HEALTH LITERACY1
GEORGE ISHAM (Chair), Senior Advisor, HealthPartners, Senior Fellow, HealthPartners Institute for Education and Research
WILMA ALVARADO-LITTLE, Director, Community Engagement/Outreach, University at Albany
CINDY BRACH, Senior Health Policy Researcher, Agency for Healthcare Research and Quality
GEM DAUS, Public Health Analyst, Health Resources and Services Administration
BENARD DREYER, Professor of Pediatrics, New York University School of Medicine
LAURIE FRANCIS, Senior Director of Clinic Operations and Quality, Oregon Primary Care Association
JILL GRIFFITHS, Vice President, Communications, Aetna
LORI HALL, Consultant, Health Education, Eli Lilly and Company
LINDA HARRIS, Team Leader, Health Communication and eHealth Team, U.S. Department of Health and Human Services
BETSY HUMPHREYS, Deputy Director, National Library of Medicine
MARGARET LOVELAND, Senior Director, Global Medical Affairs, Merck & Co., Inc.
PATRICK MCGARRY, Vice President, New Business Inovation and Connected Health, American Academy of Family Physicians
RUTH PARKER, Professor of Medicine, Pediatrics, and Public Health, Emory University School of Medicine
TERRI ANN PARNELL, Vice President, Health Literacy and Patient Education, North Shore–Long Island Jewish Health System
KIM PARSON, Consumer Experience Center of Excellence, Humana
KAVITA PATEL, Managing Director for Clinical Transformation and Delivery, Brookings Institute
SUSAN PISANO, Vice President of Communications, America’s Health Insurance Plans
ANDREW PLEASANT, Senior Director for Health Literacy and Research, Canyon Ranch Institute
LINDSEY ROBINSON, President, California Dental Association
BERNARD ROSOF, Co-Chairman, National Priorities Partnership, National Quality Forum
RIMA RUDD, Senior Lecturer on Health Literacy, Education, and Policy, Harvard University School of Public Health
_______________________
1Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution.
STEVEN RUSH, Director, Health Literacy Innovations, UnitedHealth Group
PAUL SCHYVE, Senior Advisor, Quality Improvement, The Joint Commission
ALAN TENNENBERG, Vice President, Global Health Worldwide, Johnson & Johnson
PATRICK WAYTE, Vice President, Marketing and Health Education, American Heart Association
WINSTON WONG, Medical Director, Community Benefit Disparities Improvement and Quality Initiatives, Kaiser Permanente
IOM Staff
LYLA M. HERNANDEZ, Roundtable Director
MELISSA G. FRENCH, Associate Program Officer
ANDREW LEMERISE, Research Associate
ANGELA MARTIN, Senior Program Assistant
ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practice
Reviewers
This workshop summary has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published workshop summary as sound as possible and to ensure that the workshop summary meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this workshop summary:
SHARON BARRETT, Health Literacy Staff Consultant, Association of Clinicians for the Underserved
RACHEL BRIGHT, Associate Manager, Changing Diabetes Policy, Public Affairs Strategy & Public Policy, Novo Nordisk, Inc.
ALLISON LACE, Nurse Manager, St. Joseph Hospital
PATRICIA ROSSLEY, CLAS Coordinator, AmeriHealth Caritas
Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the workshop summary before its release. The review of this workshop summary was overseen by Hugh Tilson, University of North Carolina at Chapel Hill. Appointed by the Institute of Medicine, he was responsible for making certain that an
independent examination of this workshop summary was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this workshop summary rests entirely with the rapporteurs and the institution.
Acknowledgments
The sponsors of the Institute of Medicine Roundtable on Health Literacy made it possible to plan and conduct the workshop Discharge Instructions and After-Visit Summaries, which this report summarizes. Sponsors from the U.S. Department of Health and Human Services are the Agency for Healthcare Research and Quality; Health Resources and Services Administration, and the Office of Disease Prevention and Health Promotion. Non-federal sponsorship was provided by California Dental Association; East Bay Community Foundation (Kaiser Permanente); Eli Lilly and Company; Humana; Johnson & Johnson; Merck and Co., Inc.; and the UnitedHealth Group.
The roundtable wishes to express its gratitude to the following speakers for their very interesting and stimulating presentations: John Byrne, Darren DeWalt, Benard Dreyer, Alex Federman, Alice Horowitz, Charles Lee, Man Wai Ng, Michael Paasche-Orlow, Ruth Parker, Joshua Seidman, Avniel Shetreat-Klein, Rachel Solotaroff, and Mark Williams.
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2 OVERVIEW OF ISSUES INVOLVED IN CREATING BETTER DISCHARGE INSTRUCTIONS
Discharge Instructions and Health Literacy: Policies and Their Implications
Inpatient and Ambulatory Discharge Summaries
Link Between Health Literate After-Visit Summaries and Discharge Instructions and Improved Outcomes
3 INPATIENT DISCHARGE SUMMARIES
4 OUTPATIENT AFTER-VISIT SUMMARIES
VA Loma Linda Healthcare System After-Visit Summary
5 APPROACHES TO DEVELOPING IMPROVED DISCHARGE INSTRUCTIONS
Project RED: Reengineering the Discharge Process
Discharge Instructions: Patient Values and Challenges
B Biographical Sketches of Workshop Speakers
FIGURES
2-1 Example of a discharge instruction sheet with useful features
2-2 Mechanistic pathway by which discharge instructions impact outcomes
3-1 Discharge Patient Education Tool
ACA | Patient Protection and Affordable Care Act |
AHRQ | Agency for Healthcare Research and Quality |
BOOST | Better Outcomes by Optimizing Safe Transitions |
CMS | Centers for Medicare & Medicaid Services |
CPRS | Computerized Patient Record System |
EHR | electronic health record |
IOM | Institute of Medicine |
PCP | primary care physician |
PEMAT | Patient Education Materials Assessment Tool |
RED | Re-Engineered Discharge |
SAM | Suitability Assessment of Materials |
VHA | Veterans Health Administration |