Implementing a patient-oriented discharge summary to improve hospital-to-home transitions in older adults: lessons from a hybrid study

TL;DR

A one-page discharge summary tool improved older adults' perception of hospital-to-home care transitions but faced challenges in consistent use.

Contribution

The study introduces and evaluates the Patient-Oriented Discharge Summary (PODS) as a co-designed tool for hospital discharge transitions.

Findings

PODS participants had significantly higher Care Transition Measure scores compared to controls.

PODS supported structured discharge teaching and dialogue but had variable completeness and limited home usefulness.

Barriers like workload and workflow integration limited PODS effectiveness.

Abstract

Hospital discharge is a vulnerable transition for older adults who often leave with limited understanding of their health and care instructions. This study evaluated the implementation and outcomes the Patient-Oriented Discharge Summary (PODS), a one-page co-designed tool to support hospital-to-home transitions.

Using a hybrid type II design, we combined a quasi-experimental pre–post study with an implementation evaluation in a Swiss acute care unit. Patients aged ≥50 years discharged home were allocated to control (n = 55) or intervention (PODS; n = 56). The primary outcome was perceived quality of care transition measured using the Care Transition Measure (CTM-15). Implementation outcomes were assessed through surveys, focus groups and interviews with healthcare professionals.

PODS participants reported higher CTM-15 scores than controls (74.4 vs. 62.3, p < 0.001). Implementation findings showed that the PODS structured discharge teaching and supported dialogue but its blank, collaboratively completed format led to variable completeness and limited usefulness at home. Persistent barriers included workload, workflow integration, and uneven interprofessional engagement.

PODS improved perceived quality of care transition, primarily through the relational and educational processes it structures rather than the written document alone. While valuable, PODS alone appears insufficient; combining structured tools with contextual and organizational supports may enhance effectiveness.

Clinical Trial Registration:
clinicaltrials.gov, identifier (NCT06123546).

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