Eduovisual
Patient Safety & Systems-Based Practice
Discharge planning and readmission prevention
— Hospital readmission = unplanned return to inpatient status within 30 days of discharge
— CMS Hospital Readmissions Reduction Program (HRRP) penalizes excess readmissions for AMI, HF, pneumonia, COPD, CABG, and elective THA/TKA
— National 30-day all-cause readmission rate ~14%; costs Medicare >$26 billion annually
— Tests longitudinal thinking: hospital discharge is a high-risk transition of care, not an endpoint
— Roughly 20% of Medicare patients are readmitted within 30 days; nearly half of these are considered preventable
— Most readmissions occur within the first 7–15 days post-discharge — the "post-hospital syndrome" window of physiologic and cognitive vulnerability
— Age ≥75, polypharmacy (≥5 meds), prior hospitalization within 6 months
— Heart failure, COPD, cirrhosis, ESRD on HD, sickle cell disease
— Cognitive impairment, depression, frailty, low health literacy
— Limited social support, housing insecurity, food insecurity, lack of PCP
— Substance use disorder, polysubstance, ongoing opioid therapy
— Discharge to skilled nursing facility (paradoxically higher than home with services in some cohorts)
— LACE index (Length of stay, Acuity, Comorbidity, ED visits in prior 6 mo): score ≥10 = high risk
— HOSPITAL score: hemoglobin, oncology, sodium, procedure, index admission type, prior admissions, length of stay
— Use on admission, not at discharge, so the care plan can be built around risk
Board pearl: On Step 3, the moment a high-risk patient is admitted, the correct answer often involves initiating discharge planning on day 1 — engaging case management, identifying caregiver, and clarifying goals of care before the acute issue is even fully resolved.
Key distinction: Readmission ≠ recidivism or failure; the testable construct is preventability through coordinated transitions, not avoidance of legitimate care.
— Patient returns 5–12 days after discharge with a different problem than the index admission
— Common returns: dehydration, AKI, falls, delirium, medication adverse events, uncontrolled pain, missed diagnoses
— Deconditioning, sleep deprivation, and nutritional debt from the index stay create a window of generalized vulnerability
— Medication reconciliation gaps: "I didn't know which blood pressure pill to keep taking"
— Discharge instruction comprehension: ask teach-back — "Tell me in your own words when to call the doctor"
— Follow-up appointment: scheduled? transportation? insurance active? PCP accepting?
— Equipment and services: home oxygen delivered? home health nurse actually visited? glucometer in hand?
— Caregiver status: who is helping with meds, meals, mobility, wound care?
— Red-flag symptom recognition: does patient know weight gain ≥3 lb/day = call HF clinic?
— HF readmission: dietary indiscretion, diuretic non-adherence, NSAID use, missed weight monitoring
— COPD readmission: inhaler technique failure, missed pulmonary rehab, ongoing smoking, no rescue plan
— Pneumonia readmission: incomplete antibiotic course, undiagnosed post-obstructive cause, aspiration risk unaddressed
— AMI readmission: DAPT non-adherence (cost!), missed cardiac rehab, depression
— Cirrhosis readmission: lactulose under-dosing, SBP prophylaxis missed, diuretic-induced AKI
— Screen for transportation, housing, food, utilities, interpersonal safety (CMS-mandated SDOH screening)
— Ask about cost: "Did you fill all your prescriptions?" — primary non-adherence runs 20–30%
Step 3 management: When a recently discharged patient re-presents, the first three questions are: (1) Did you get your medications? (2) Did you keep your follow-up appointment? (3) What did you eat and drink yesterday? These uncover the majority of preventable readmissions before you order a single lab.
— Cognition: Mini-Cog or 3-item recall before discharge teaching; delirium screen (CAM) within 24 h of discharge
— Mobility: observed ambulation, stairs if relevant, Timed Up and Go (>12 sec = fall risk)
— ADL/IADL capacity: can the patient self-medicate, prepare meals, manage finances?
— Vision and hearing: critical for reading med bottles and hearing instructions
— Health literacy: Newest Vital Sign or REALM-SF if formal; otherwise teach-back
— Afebrile ≥24 h, stable vitals ≥8–24 h, oxygenation at or near baseline on room air or stable home O2
— Eating, drinking, voiding, ambulating to baseline (or planned SNF level)
— Pain controlled on the oral regimen patient will go home on — not on IV
— Tolerating oral medications for ≥1 dose cycle
— Bowel function returned (especially post-op, post-opioid initiation)
— HF: euvolemic by exam, weight at dry weight, on goal-directed oral diuretic ≥24 h, K+ and Cr stable
— COPD: SpO2 ≥88% on prescribed O2, inhaler technique demonstrated, oral steroid taper clear
— Pneumonia: meets all 5 clinical stability criteria (HR, RR, BP, SpO2, mental status, PO intake)
— DKA: anion gap closed, transitioned to SC insulin with 1–2 h overlap of IV
— Confirmed destination (home, SNF, rehab, shelter, group home)
— Caregiver identified and educated
— Equipment delivered or scheduled
— Prescriptions filled — ideally meds-to-beds at the bedside before discharge
CCS pearl: On a CCS case, do not click "discharge home" until you've ordered: medication reconciliation, follow-up appointment, patient education, and (when applicable) home health services. Premature discharge in CCS is scored as a management error even if clinical parameters look fine.
— Performed at three transitions: admission, any level-of-care change, and discharge
— Compare: pre-admission med list, inpatient med list, discharge med list — reconcile every line
— Adverse drug events occur in ~20% of patients within 3 weeks of discharge; ~70% are preventable
— Use a pharmacist whenever possible — pharmacist-led reconciliation reduces readmissions in multiple RCTs
— Drug name (generic and brand), dose, route, frequency, duration, indication
— Explicit STOP list: which prior medications are discontinued and why
— Explicit HOLD list: e.g., hold lisinopril until Cr <1.5, hold metformin until eGFR rechecked
— Explicit NEW list: include why ("new for atrial fibrillation — prevents stroke")
— Reconcile against insurance formulary; substitute if non-covered to prevent primary non-adherence
— Anticoagulants (warfarin INR plan, DOAC renal dosing), insulin, opioids, digoxin
— Antihypertensives (orthostasis risk in elderly), diuretics (electrolyte monitoring plan)
— Antibiotics with specific durations — write the stop date, not just "x 7 days"
— Steroid tapers — write the full schedule with dates
— Must reach the receiving clinician within 48 hours (Joint Commission and CMS expectation)
— Required: admission diagnosis, hospital course, discharge diagnoses, procedures, pending labs/cultures, follow-up appointments, medication changes, code status, functional status
— Pending results at discharge are present in ~40% of patients and are a major safety hazard — flag them explicitly and assign ownership
Board pearl: When a vignette describes a patient who returns with hyperkalemia after discharge on a new ACE inhibitor and continued spironolactone — the failure point is medication reconciliation, not the prescribing decision. The answer is institutional med-rec process improvement, often by pharmacist.
— LACE+: adds patient demographics, prior ED use, ICU days — better calibration than LACE
— HOSPITAL score: ≥7 = high risk for potentially avoidable readmission
— PRA (Probability of Repeated Admission) for Medicare outpatients
— Disease-specific: Seattle Heart Failure Model, BODE index for COPD
— Project RED (Re-Engineered Discharge) — Boston Medical Center, 11-component bundle: reduces readmissions ~30%
— Key elements: discharge advocate, after-hospital care plan booklet, follow-up call within 72 h
— Project BOOST (Better Outcomes for Older adults through Safe Transitions) — SHM
— Care Transitions Intervention (Coleman model) — transition coach, 4 pillars: medication self-management, personal health record, follow-up, red flags
— Transitional Care Model (Naylor) — APRN-led, particularly for HF; reduces readmissions and mortality
— Post-discharge phone call within 48–72 hours by nurse or pharmacist — reviews meds, symptoms, appointments
— Remote patient monitoring (weight scales for HF, pulse oximetry for COPD) — variable evidence, useful in selected high-risk patients
— Patient portal messaging and televisit follow-up — now CMS reimbursable
— Community health workers and peer navigators reduce readmissions in safety-net populations
— Hospital-at-home programs (CMS Acute Hospital Care at Home waiver) — for selected stable patients
— Skilled home health: PT/OT, nursing wound care, IV antibiotics via OPAT
Key distinction: A transition of care visit (CPT 99495/99496) is a billable Medicare service requiring contact within 2 business days and face-to-face visit within 7 or 14 days. It is reimbursed at a higher rate than a standard follow-up — testable as a systems-based practice intervention that aligns financial incentives with quality.
— Low risk (young, single problem, intact social support, no high-risk meds): standard discharge instructions, PCP follow-up within 2–4 weeks
— Moderate risk (chronic disease, polypharmacy, lives alone): add post-discharge call, follow-up within 7–14 days, consider home health
— High risk (LACE ≥10, HF/COPD/cirrhosis, frail, prior 30-day readmission): multidisciplinary bundle, follow-up within 7 days, transition coach, pharmacist med rec
— Discharge planning, complete communication, availability/timeliness of outpatient follow-up, medication safety, patient education, enlisting social support, advance care planning, coordinating care among team members
— Discharge summary completed and sent
— Medication reconciliation finalized with patient teach-back
— Follow-up appointment scheduled (not just "call your doctor") — ideally before patient leaves
— Red-flag symptom list given in writing at appropriate literacy level (5th–6th grade)
— Transportation confirmed
— Equipment delivered or scheduled
— Pending labs/studies documented with responsible clinician
— Patient and caregiver acknowledge understanding via teach-back
— Home with self-care: independent, stable, good support
— Home with home health: needs nursing, PT/OT, or IV therapy but otherwise safe
— SNF: needs 24-hr nursing, rehab potential, Medicare 3-midnight rule (waived under some ACOs)
— Inpatient rehab: ≥3 hours therapy/day tolerated, multiple disciplines needed
— LTACH: prolonged complex medical care (ventilator weaning, complex wounds)
— Hospice: limited prognosis, comfort-focused goals
Step 3 management: A common stem — "78-year-old with new HF exacerbation, lives alone, missed prior appointments, on 9 medications." Best next step is multidisciplinary discharge planning with pharmacist med rec, home health referral, and follow-up within 7 days, not simply discharging on optimized GDMT.
— Start with the pre-admission list, then justify every addition and every continuation
— Prefer once-daily dosing, generic, and on-formulary agents
— Use the lowest effective dose of new medications, especially in the elderly
— Avoid prescribing cascades — new symptom from a new drug? Stop the drug, don't add another
— Benzodiazepines and Z-drugs in elderly — taper, do not abruptly stop
— Anticholinergics (diphenhydramine, oxybutynin, TCAs) — falls, delirium
— PPIs without ongoing indication — reassess after 8 weeks
— Sliding-scale insulin alone — replace with basal-bolus or basal + correction
— NSAIDs in CKD, HF, or anticoagulated patients
— HF with reduced EF: ARNI (or ACEi/ARB), beta-blocker (carvedilol/metoprolol succinate/bisoprolol), MRA, SGLT2i — the "four pillars," initiated before discharge whenever tolerated
— Post-MI: DAPT (aspirin + P2Y12), high-intensity statin, beta-blocker, ACEi (if EF <40% or DM/HTN/CKD), nitroglycerin PRN
— COPD exacerbation: LABA/LAMA ± ICS, prednisone taper to complete 5 days total, smoking cessation pharmacotherapy
— Stroke/TIA: antiplatelet or anticoagulation, high-intensity statin, BP control, A1c <7%
— VTE: DOAC or warfarin with bridging if indicated, clear duration (3 mo provoked, indefinite unprovoked with low bleed risk)
— Run prescriptions through formulary check before discharge — primary non-adherence due to cost is a leading driver of readmission
— Use meds-to-beds programs: prescriptions filled at hospital pharmacy delivered to bedside before discharge — reduces readmissions ~15–20%
— 340B and patient assistance programs for high-cost drugs (sacubitril/valsartan, DOACs, biologics)
Board pearl: Initiating GDMT for HFrEF before discharge (even at low doses) dramatically improves long-term adherence vs. "start as outpatient" — testable correct answer in HF readmission stems.
— CPT 99495: moderate complexity, face-to-face visit within 14 days, contact within 2 business days
— CPT 99496: high complexity, face-to-face within 7 days, contact within 2 business days
— Both require medication reconciliation by the date of the face-to-face visit
— Higher RVUs than standard E/M — aligns financial and quality incentives
— CPT 99490: ≥20 min/month non-face-to-face for patients with ≥2 chronic conditions
— Requires patient consent, comprehensive care plan, 24/7 access to care team
— Reduces ED visits and readmissions in Medicare populations
— Must be homebound (leaving home requires considerable effort)
— Must require intermittent skilled care (nursing, PT, OT, SLP)
— Ordered by physician/NP/PA who has had face-to-face encounter within 90 days before or 30 days after start of care
— Recertification every 60 days
— Medicare Part A: requires 3-midnight qualifying inpatient stay (observation days do NOT count) — major patient safety issue, often surprises patients
— Covers up to 100 days/spell of illness; days 1–20 fully covered, 21–100 with copay
— Waived under some Medicare Advantage plans and ACO models
— Indicated for endocarditis, osteomyelitis, complicated SSTI requiring prolonged IV
— Requires PICC line, weekly labs (CBC, CMP, drug levels), ID follow-up
— Contraindicated in active IVDU without supervised model (now evolving — many centers offer OPAT to PWID with appropriate supports)
CCS pearl: When the CCS clock shows a patient ready for hospital discharge but needing IV antibiotics, ordering PICC line + ID consult for OPAT + home health + outpatient ID follow-up all together scores higher than discharging home on oral antibiotics that don't cover the organism.
— 1 in 5 Medicare patients readmitted within 30 days
— Post-hospital syndrome especially severe: 30% have new ADL impairment vs. baseline
— Delirium during admission predicts cognitive decline and readmission
— Medication review with Beers/STOPP — flag every PIM (potentially inappropriate medication)
— Fall risk assessment: home safety eval by OT, remove loose rugs, install grab bars
— Cognitive screen before discharge — if impaired, mandatory caregiver education and pillbox/blister pack
— Hearing/vision aids in place for discharge teaching
— Advance care planning revisited — hospitalization is a sentinel event for goals-of-care conversations
— Consider PACE (Program of All-Inclusive Care for the Elderly) for nursing-home-eligible patients
— Re-dose every renally cleared medication using discharge eGFR (not admission)
— DOAC dose adjustments: apixaban (2.5 mg BID if 2 of: age ≥80, weight ≤60 kg, Cr ≥1.5), rivaroxaban contraindicated CrCl <15
— Avoid NSAIDs absolutely; counsel on OTC ibuprofen/naproxen
— Metformin: hold if eGFR <30; reassess if 30–45
— Schedule outpatient labs within 3–7 days if diuretics, ACEi/ARB, MRA, or new contrast exposure
— Lactulose titrated to 2–3 soft BMs/day — caregiver education essential
— Rifaximin for HE prophylaxis if prior episode
— SBP prophylaxis with norfloxacin/ciprofloxacin if prior SBP or ascitic protein <1.5 with renal/hepatic dysfunction
— Avoid NSAIDs, aminoglycosides, sedatives; cautious diuretic dosing with daily weights
— Hepatology follow-up within 7 days; MELD-driven transplant evaluation
Step 3 management: Cirrhotic patient discharged after HE — the answer involving caregiver-administered lactulose with rifaximin, hepatology follow-up in 7 days, and clear red-flag instructions for sleep changes or confusion beats answers focused only on medications.
— "Medical home" coordination — communicate with PCP and any specialists
— Weight-based dosing rechecked at discharge; liquid formulations with mL (not tsp)
— Car seat check for neonates and infants
— Immunization status updated — catch up before discharge if behind
— School/daycare return criteria documented
— Chronic complex children: ensure all subspecialty appointments scheduled; tech-dependent kids (G-tube, trach) need equipment delivered before discharge
— Postpartum visit within 3 weeks, comprehensive visit by 12 weeks (ACOG, updated from old 6-week single visit)
— Severe-range BP (≥160/110) — readmission risk for postpartum preeclampsia/eclampsia; teach red flags (headache, vision changes, RUQ pain, dyspnea)
— Mental health screening (EPDS) — postpartum depression peaks 4–6 weeks
— Contraception counseling and provision before discharge; LARC if desired
— Breastfeeding support, lactation consult follow-up
— Warm handoff to outpatient psychiatry — appointment scheduled before discharge, not just referral
— Suicide safety planning, lethal means restriction counseling
— Buprenorphine or methadone initiated inpatient for OUD reduces post-discharge mortality and readmission — bridge to outpatient MAT clinic within 72 h
— Naloxone prescribed at discharge for any patient on opioids or with OUD history
— Alcohol use disorder: naltrexone, acamprosate, or disulfiram at discharge; thiamine continued
— CMS now requires SDOH screening for inpatient encounters (Z-codes)
— Connect to: SNAP, WIC, Section 8, LIHEAP, Medicaid enrollment assistance
— IPV screening — provide safety planning resources; do not document address if shelter
Board pearl: "Discharge to address" matters: a patient experiencing homelessness discharged to "the street" with insulin and a glucometer is a foreseeable harm — the correct answer involves medical respite or shelter coordination before discharge.
— Occur in ~20% of patients in the 3 weeks post-discharge; ~70% preventable or ameliorable
— Top offenders: anticoagulants, antibiotics, opioids, insulin, cardiovascular drugs
— Mechanisms: duplicate therapy, omission, wrong dose, interaction, monitoring failure
— Example: continued home spironolactone + new ACEi → hyperkalemic arrest
— Example: warfarin restarted at home dose after antibiotic course → supratherapeutic INR, GI bleed
— ~40% of patients have pending results at discharge; up to 1/3 are clinically actionable
— Examples: blood cultures finalizing, biopsy pathology, incidental imaging findings
— Safety practice: structured pending-results section in discharge summary with named responsible clinician and tickler in EHR
— Premature closure: HF readmission turns out to be amyloidosis; "pneumonia" was actually lung cancer
— Aspiration not addressed: stroke patient sent home without swallow study clearance → recurrent pneumonia
— Failure to follow up incidentaloma → delayed cancer diagnosis (medico-legal risk)
— Falls (10–15% within 30 days), delirium, functional decline, weight loss, pressure injuries
— Caregiver burnout — sentinel event for nursing home placement
— C. difficile from inpatient antibiotics — peak onset 1–4 weeks after discharge
— CLABSI/CAUTI if lines or catheters left in
— VTE — extended prophylaxis indicated after major orthopedic, abdominopelvic cancer surgery
— Surgical site infection — typically 5–14 days post-op
Key distinction: A patient bounce-back within 72 hours usually represents premature discharge or missed diagnosis; bounce-back at 2–3 weeks usually represents failed transition (medication, follow-up, SDOH). The two require different root-cause analyses and different system fixes.
— Unable to perform basic ADLs and no caregiver
— Active suicidal ideation with plan/intent
— Unstable housing with medical needs (insulin requiring refrigeration, oxygen)
— Suspected elder abuse, child abuse, or IPV — engage social work and protective services
— Cognitive impairment without supervision capacity
— Inability to afford or access critical medications
— Inpatient rehab facility (IRF): ≥3 hr/day therapy tolerance, ≥2 disciplines, expected functional gain
— Skilled nursing facility (SNF): lower-intensity rehab or skilled nursing needs
— Long-term acute care hospital (LTACH): medically complex (vent weaning, complex wounds, multi-system)
— Medical respite: for patients experiencing homelessness who need recovery time
— Hospital-at-home: acute-level care in the home for selected stable patients
— Hospice: comfort care, life expectancy ≤6 months — inpatient hospice unit, residential hospice, or home hospice with continuous care for symptom crisis
— Case management/social work: any high-risk discharge, SDOH concerns, insurance navigation
— Pharmacy: polypharmacy, high-risk meds, transitions involving anticoagulants/insulin/opioids
— PT/OT: any functional decline from baseline, falls, equipment needs
— SLP: dysphagia screen before any post-stroke or post-extubation oral diet
— Palliative care: serious illness, symptom burden, goals-of-care clarification
— Geriatrics consult: frailty, delirium, polypharmacy in age ≥75
— Observation status (outpatient) days do not count toward the SNF 3-midnight rule
— Patients may be surprised by bills and lose SNF coverage — communicate status clearly
— Use CMS Two-Midnight Rule for appropriate status determination
CCS pearl: When CCS clock shows a frail elder with a new oxygen requirement, no caregiver, and missed prior appointments, don't discharge home — order SNF placement, PT eval, social work, and home oxygen setup; discharge home in this scenario is scored as unsafe.
— Non-adherence (cost, complexity, side effects, health literacy)
— Adverse drug event (drug-drug, drug-disease, dosing error)
— Prescribing cascade
— Medication reconciliation failure at discharge
— High-risk drug class without monitoring (warfarin without INR, lithium without level, methotrexate without CBC)
— No follow-up appointment scheduled
— Appointment scheduled but patient could not attend (transportation, work, caregiver issues)
— Pending lab/imaging not followed up
— Home health ordered but not delivered
— Specialist referral made but never completed
— Patient did not understand red-flag symptoms
— Did not know which medication to hold or stop
— Could not perform required self-care (wound care, glucose monitoring, weight tracking)
— Cultural/linguistic mismatch — interpreter not used or used inadequately
— Discharge summary not transmitted in time
— PCP not informed of hospitalization
— Specialist recommendations not implemented
— Care fragmented across systems with no shared EHR
— Prior authorization or formulary issues blocked critical medications
Step 3 management: When a Step 3 stem describes a 30-day readmission, the answer choices often include both clinical intensification (more diuretic, switch antibiotic) and process improvements (pharmacist med rec, transition coach, post-discharge phone call). The latter typically wins when the failure point is clearly a transition-of-care gap.
— Roughly 25–50% of 30-day readmissions are considered preventable; the rest reflect natural disease trajectory or unrelated new illness
— HRRP penalties are risk-adjusted but imperfect — safety-net hospitals are disproportionately penalized
— End-stage HF with progressive volume overload despite optimal GDMT — consider advanced therapies (transplant, LVAD) or transition to hospice
— Advanced COPD with frequent exacerbations despite triple therapy — pulmonary rehab, palliative referral
— Decompensated cirrhosis with refractory ascites — TIPS evaluation or transplant listing
— Cancer-related: febrile neutropenia, malignant effusions, pain crises — often unavoidable
— Patient discharged after pneumonia, returns with hip fracture — not a "preventable readmission" but counted under all-cause metrics
— New diagnosis discovered during readmission (e.g., GI bleed reveals colon cancer) — sometimes the readmission is the lucky catch
— Hospital-acquired infection appearing post-discharge (C. diff, SSI, CLABSI)
— Procedure complication: post-cardiac cath bleeding, post-endoscopy perforation
— Adverse effect of inpatient medication that persists (e.g., steroid-induced psychosis)
— CMS attribution: the discharging hospital owns the readmission for HRRP purposes, regardless of cause
— Accountable Care Organizations (ACOs) and bundled payments shift incentives toward longitudinal management
Key distinction: A patient with end-stage HF readmitted 4 times in 6 months despite perfect care is not a "system failure" — it's a goals-of-care opportunity. The right answer is often palliative care consultation and advanced HF therapy discussion, not more diuretic titration.
— Every discharge should anticipate and prevent the next admission
— Build the plan around the 4 Pillars (Coleman): meds, personal health record, follow-up, red flags
— HF: GDMT optimization (4 pillars), daily weights, fluid <2 L, sodium <2–3 g, flu/pneumococcal/COVID vaccines, cardiac rehab, depression screen
— AMI: DAPT duration clear, statin, beta-blocker, ACEi/ARB, cardiac rehab referral (Class I — under-utilized), smoking cessation, BP/lipid/glucose targets
— Stroke: antiplatelet/anticoagulation, statin, BP <130/80, A1c <7%, carotid management, swallowing, post-stroke depression screening
— COPD: smoking cessation pharmacotherapy + counseling, vaccines, pulmonary rehab (post-exacerbation within 4 weeks — strong evidence), action plan with rescue prednisone/antibiotic
— Cirrhosis: alcohol cessation, HE prophylaxis, SBP prophylaxis if indicated, varices surveillance, HCC screening every 6 months, vaccines
— Diabetes: A1c goal individualized, SGLT2i/GLP-1 if ASCVD/CKD/HF, statin, BP, foot/eye/kidney surveillance, hypoglycemia education
— VTE: anticoagulation duration explicit, provoked vs. unprovoked, recurrence risk assessment
— Vaccinations updated (influenza, pneumococcal, COVID, RSV if eligible, zoster)
— Cancer screening current (mammography, colonoscopy, cervical, lung CT)
— Mental health screen (PHQ-2/9)
— Substance use review and intervention
— Advance care planning revisited
Board pearl: Cardiac rehab and pulmonary rehab are among the most under-utilized, highest-impact secondary prevention interventions on Step 3 — referring at discharge is frequently the correct answer in post-MI, post-CABG, and post-COPD-exacerbation stems.
— 48–72 hours: post-discharge phone call (nurse/pharmacist) — review meds, symptoms, appointments
— 7 days: high-risk face-to-face follow-up (HF, COPD, sepsis, post-surgical, frail elder) — CPT 99496
— 14 days: moderate-risk follow-up — CPT 99495
— 30 days: complete medication reconciliation, review pending studies, repeat labs as needed
— 90 days: stabilize chronic disease management, transition fully to outpatient cadence
— HF: daily home weight log; clinic visit at 7 d → 2 wk → 4 wk; BMP at 1–2 weeks after diuretic/ACEi/ARNI changes; titrate GDMT every 2–4 weeks to target doses
— AKI/CKD: BMP within 1 week after RAAS-inhibitor, diuretic, contrast
— VTE on warfarin: INR within 3–7 days; on DOAC, follow-up at 1 month with renal function
— DKA: endocrine follow-up within 1–2 weeks; verify insulin technique, glucometer use
— Post-MI: cardiology 2–6 weeks, lipid panel at 4–12 weeks on statin
— Post-stroke: neurology 1–3 months, BP daily home log, swallow re-eval if dysphagia
— Post-op: surgeon visit at 1–2 weeks; suture/staple removal; activity progression
— Cardiac rehab post-ACS/CABG/HF — start within 1–3 weeks
— Pulmonary rehab post-COPD exacerbation — within 4 weeks
— PT/OT for any functional decline
— Diabetes self-management education (DSME) — covered by Medicare
— Smoking cessation counseling + pharmacotherapy at every visit
— Mental health referral for PHQ-9 ≥10
— HF: weight log, BP/HR log, symptom diary
— COPD: action plan, peak flow if asthma overlap
— Diabetes: SMBG or CGM logs, hypoglycemia events
— Anticoagulation: bleeding diary, medication list card
Step 3 management: "When should this newly discharged HFrEF patient be seen?" — the answer is within 7 days, in person, with BMP and weight check, and titration of GDMT initiated, not "in 4–6 weeks at routine PCP follow-up."
— Patients have the right to leave AMA — but AMA discharge is not a free pass for the team
— Document: capacity assessment, risks explained in patient's language, alternatives offered, follow-up plan still arranged, prescriptions still given, naloxone if relevant
— AMA does not invalidate insurance coverage in most cases (common myth — do not use as coercion)
— If patient lacks capacity, AMA is not valid — engage surrogate decision-maker per state hierarchy
— Discharging a patient to a situation of foreseeable serious harm (no shelter, no caregiver, no food, no meds) can constitute patient abandonment and a Joint Commission sentinel event
— Engage social work, ethics committee, risk management when impasses arise (e.g., insurance won't cover SNF, family refuses to take patient home)
— Suspected elder abuse, child abuse, IPV (state-dependent) — Adult Protective Services, Child Protective Services
— Impaired driver concerns — state-dependent reporting to DMV (post-stroke, seizure, dementia)
— Communicable diseases — public health reporting (TB, syphilis, etc.) does not stop at discharge
— HIPAA permits sharing PHI with subsequent treating providers — push the discharge summary to PCP, SNF, home health
— Special protections: substance use treatment records (42 CFR Part 2), mental health, HIV in some states
— Patient portal access: ensure patient and authorized caregivers have it
— Joint Commission requires standardized hand-off (I-PASS, SBAR)
— Discharge to SNF/LTACH: medication list, code status, allergies, pending issues, recent vitals, baseline cognitive/functional status
— Disparities in readmission by race, ethnicity, language, SES — track and address
— Use professional interpreters (not family) for all discharge teaching when language discordant — failure is a documented safety event
Board pearl: A patient with capacity wishes to leave AMA with active endocarditis. The correct steps: assess and document capacity, explain risks, still prescribe oral antibiotics, arrange follow-up, give naloxone if PWID, and offer to readmit any time — do not punitively withhold care.
— ~14% all-cause 30-day Medicare readmission rate
— ~25–50% of readmissions considered preventable
— Pending test results at discharge: ~40% of patients; ~10% clinically actionable
— Adverse drug events post-discharge: ~20%; ~70% preventable
— Post-hospital phone call within 72 hours and 7-day follow-up are the two single highest-yield interventions
— HRRP: penalizes excess readmissions for AMI, HF, pneumonia, COPD, CABG, elective hip/knee
— Hospital-Acquired Condition Reduction Program: bottom-quartile hospitals lose 1% of Medicare payments
— Value-Based Purchasing: ties reimbursement to quality metrics
— MSSP / ACO REACH: shared-savings models that reward longitudinal management
— Bundled Payments for Care Improvement (BPCI): episode-based payment including 30/60/90-day post-discharge
— Project RED, Project BOOST, Care Transitions Intervention (Coleman), Transitional Care Model (Naylor), Interventions to Reduce Acute Care Transfers (INTERACT for SNF)
— Medication reconciliation (NPSG 03.06.01)
— Communicate accurately (hand-off)
— Use two patient identifiers
— Improve recognition and response to deteriorating patients
— Med rec with teach-back
— Follow-up scheduled before patient leaves
— Pending results assigned
— Red flags in writing
— Discharge summary to PCP within 48 h
— Cardiac rehab referral post-MI/CABG — Class I, under-utilized
— Pulmonary rehab within 4 weeks of COPD exacerbation
— Buprenorphine started inpatient for OUD reduces overdose mortality
— Influenza/pneumococcal/COVID vaccines at discharge — opportunistic
— Naloxone for any opioid prescription
Key distinction: Step 2 tests what to prescribe at discharge; Step 3 tests how to ensure the patient actually takes it, follows up, and stays out of the hospital — process measures, transition tools, and systems thinking.
— "72M with HFrEF discharged 8 days ago presents with dyspnea, 6 lb weight gain. He stopped his torsemide because he 'felt better.'"
— Trap answers: more IV diuretic alone; switch to bumetanide
— Right answer: admit, diurese, AND arrange post-discharge phone call, 7-day clinic follow-up, home health, and HF nurse education for the next discharge
— "81F on 11 medications discharged after pneumonia returns with confusion and falls"
— Trap: order CT head, MRI brain
— Right answer: pharmacist-led medication reconciliation using Beers criteria; deprescribe anticholinergics, sedatives
— "Patient discharged after pneumonia; 5 days later, blood cultures grow MRSA"
— Trap: nothing — it's the discharging team's responsibility
— Right answer: contact patient, arrange readmission or OPAT; implement systematic pending-results tracking as quality improvement
— "Post-MI patient cannot afford ticagrelor; stops both DAPT meds"
— Right answer: switch to clopidogrel (generic), patient assistance programs, meds-to-beds at discharge
— "Endocarditis patient with OUD wants to leave AMA"
— Right answer: assess capacity, harm reduction, oral antibiotics, naloxone, buprenorphine bridge, MAT clinic appointment
— "Family surprised patient does not qualify for SNF coverage"
— Right answer: patient was on observation status — does not count toward 3-midnight rule; counsel family, explore Medicaid/community options
— "Hospital wants to reduce HF 30-day readmissions"
— Right answer: implement transitional care bundle — pharmacist med rec, 72-h phone call, 7-day follow-up, home health, cardiac rehab referral
Step 3 management: When two answer choices both look "right" — one clinical, one systems-based — the systems answer wins when the failure point in the stem is clearly a transition-of-care gap.
— Start discharge planning on day 1: identify LACE/HOSPITAL risk, engage case management, clarify destination and caregiver, anticipate barriers (cost, transportation, literacy, SDOH) before they materialize at the door
— Medication reconciliation is the single highest-yield safety intervention: pharmacist-led when possible; teach-back required; meds-to-beds eliminates primary non-adherence; deprescribe using Beers/STOPP in elderly
— The 72-hour phone call + 7-day in-person follow-up are the most evidence-supported transition interventions; bill as TCM (CPT 99495/99496); pair with cardiac/pulmonary rehab and home health for highest-impact bundles
— Own the pending results, own the bounce-back: discharge summary to PCP within 48 hours, named responsible clinician for every pending lab or imaging finding, structured hand-off to SNF/home health using SBAR or I-PASS
Board pearl: On Step 3, when the vignette describes any recently discharged patient in trouble, ask first whether the failure was clinical (wrong drug, wrong dose, wrong diagnosis) or transitional (no follow-up, no reconciliation, no education, no support) — the correct answer almost always addresses the failure point identified, and the transitional answer is correct more often than trainees expect.