postdischarge

Postdischarge refers to the period after a patient is discharged from a hospital, inpatient rehabilitation facility, or other care setting. It encompasses the transition from acute care to home or another care environment and the ongoing management of health needs. Effective postdischarge care emphasizes continuity, coordination, and safety during this transition.

Core elements of postdischarge care include discharge summaries and medication reconciliation, patient and caregiver education on warning signs and when to seek help, arranging follow-up care with primary or specialty providers, and coordinating with home health services, telehealth check-ins, and social support. Ensuring access to medications, equipment, transportation, and clear lines of communication between hospital and community providers is also essential.

The objectives of postdischarge planning are to reduce adverse events after discharge, prevent avoidable readmissions, improve medication adherence, and support timely recovery and functional status. Common practices include early postdischarge contact, such as a phone or telehealth check-in within one to two days, and a follow-up appointment within seven days when appropriate. Risk stratification may be used to identify patients who need more intensive transitional care.

Challenges to effective postdischarge care include health literacy, language barriers, polypharmacy, social determinants of health, limited home support, and gaps in information transfer between hospital and community providers. Practices vary across settings and resources.

In policy and research, postdischarge care is a focus of transitional care programs and quality metrics. Successful postdischarge care relies on integrated care teams, robust information systems, and patient-centered planning to ensure safe and coordinated recovery after discharge.