# Clinical Cases: Discharge Planning and Care Transitions

## Case 1: High-Risk Discharge and Medication Reconciliation

### Clinical Image
![Medication reconciliation with pharmacist and patient](case_01_image.jpg)
*Source: [Wikimedia Commons - Pharmacy](https://commons.wikimedia.org/wiki/Category:Pharmacies) - CC BY-SA 4.0*

### Case Presentation
A 74-year-old woman with heart failure, diabetes, COPD, and chronic kidney disease is admitted for acute heart failure exacerbation. During hospitalization, her medications undergo significant changes: her furosemide is increased from 40 mg daily to 80 mg twice daily, metoprolol is uptitrated from 25 mg to 50 mg twice daily, and a new medication (spironolactone 25 mg daily) is added. Her metformin is held due to acute kidney injury and is not restarted at discharge (creatinine improved but remains 1.8 mg/dL). Her pre-admission medication list includes 14 medications. The sub-intern performs medication reconciliation by comparing the admission medication list, current inpatient orders, and discharge plan. She identifies several issues: the patient was taking lisinopril at home that was never reordered (transcription error), her as-needed albuterol inhaler needs renewal, and she cannot afford the new spironolactone without insurance coverage review. The pharmacy team identifies a patient assistance program for spironolactone. The sub-intern creates detailed discharge medication instructions in plain language with large font (the patient has macular degeneration). She explains each medication change using teach-back: "Can you tell me in your own words why we increased your water pill?" The patient's LACE score (Length of stay 5, Acute admission, 4 Comorbidities, 2 ED visits in past 6 months) is 12, indicating high readmission risk. Enhanced discharge interventions are implemented: early PCP follow-up in 3 days, home health nursing for medication teaching and weight monitoring, and a transition phone call is scheduled for 48 hours post-discharge.

### Key Learning Points
- Medication reconciliation requires comparing pre-admission, inpatient, and discharge medications; common errors include omissions, duplications, and unintentional changes
- High-risk medications at discharge include anticoagulants, insulin, diuretics, and opioids; these require specific attention and patient education
- LACE score predicts 30-day readmission risk (Length of stay, Acuity of admission, Comorbidities, Emergency visits); high-risk patients benefit from enhanced transition interventions
- Teach-back technique ("Tell me in your own words...") confirms patient understanding more reliably than simply asking "Do you understand?"

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## Case 2: Transition Phone Call and Early Follow-Up

### Clinical Image
![Nurse making post-discharge transition phone call](case_02_image.jpg)
*Source: [Wikimedia Commons - Healthcare Communication](https://commons.wikimedia.org/wiki/Category:Telecommunication) - CC BY-SA 3.0*

### Case Presentation
A 67-year-old man with diabetes and coronary artery disease is discharged after a 4-day hospitalization for NSTEMI treated with PCI and stent placement. He was started on dual antiplatelet therapy (aspirin and clopidogrel), atorvastatin was increased to 80 mg, and metoprolol was added. The sub-intern makes a transition phone call 48 hours after discharge. She uses a structured approach: "How are you feeling since you got home?" He reports doing well overall but mentions mild dizziness when standing. She asks about medications: "Can you tell me what heart medications you are taking?" He correctly identifies aspirin, clopidogrel, and atorvastatin but has not started the metoprolol because he "couldn't get it filled." The pharmacy was out of stock, and he did not know to go elsewhere. She identifies this medication access barrier and helps him locate an alternative pharmacy with same-day pickup. She asks about warning signs: "Do you remember what symptoms should bring you back to the hospital?" He correctly identifies chest pain but does not mention shortness of breath or severe bleeding. She reinforces these return precautions. She confirms his cardiology follow-up is scheduled in 1 week and PCP follow-up in 2 weeks. She documents the call, noting the medication access issue that was resolved and the additional education provided. She alerts the outpatient cardiologist about the delayed metoprolol start via secure message.

### Key Learning Points
- Transition phone calls (within 24-72 hours post-discharge) identify early problems before they lead to readmission
- Structured call elements: check on patient, review medications, assess symptoms, identify barriers, and confirm follow-up
- Medication access barriers (cost, pharmacy stock, transportation) are common and often discovered only after discharge
- Communication with outpatient providers about discharge events and transition issues ensures continuity of care

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## Case 3: Complex Discharge to Skilled Nursing Facility

### Clinical Image
![Skilled nursing facility rehabilitation with physical therapy](case_03_image.jpg)
*Source: [Wikimedia Commons - Physical Therapy](https://commons.wikimedia.org/wiki/Category:Physical_therapy) - CC BY-SA 4.0*

### Case Presentation
An 82-year-old man who lives alone is hospitalized with a hip fracture after a fall. He undergoes ORIF and has an uncomplicated surgical course. Pre-hospitalization, he was independent in ADLs, used a cane, and drove himself to appointments. Post-operatively, physical therapy assesses him and finds he requires maximal assist for transfers and cannot bear weight on the operative leg for 6 weeks. Occupational therapy notes he cannot safely prepare meals or bathe independently. He is clearly not safe to return home alone. The case manager discusses disposition options: acute rehabilitation versus subacute/SNF rehabilitation. Given his age and that he cannot tolerate 3 hours of therapy daily (required for acute rehab), subacute rehabilitation at a skilled nursing facility is recommended. The sub-intern prepares a comprehensive discharge summary including: diagnosis and procedure, surgical details and precautions (weight-bearing status, DVT prophylaxis with enoxaparin for 4 weeks), pending items (2-week follow-up radiograph, staple removal at 2 weeks), medications with specific attention to anticoagulation and pain management plan (scheduled acetaminophen, oxycodone PRN with specific quantity and tapering expectation), code status (Full Code, previously discussed), and specific therapy goals for SNF. She contacts the accepting SNF directly to verbally review the case, emphasizing the weight-bearing restriction and anticoagulation needs. The patient successfully completes 3 weeks of SNF rehabilitation and returns home with outpatient PT.

### Key Learning Points
- Disposition options must match patient needs: home alone (for independent patients), home with services (for those needing some assistance), acute rehab (for those tolerating 3+ hours therapy daily), or SNF/subacute rehab (for moderate therapy needs or those not tolerating intensive therapy)
- Discharge summaries should be transmitted within 24-48 hours and include diagnosis, hospital course, medication changes, pending items, and specific follow-up needs
- Direct communication (phone call) with accepting facilities ensures critical information is transmitted, especially for complex patients or high-risk items
- Specific information for SNF: weight-bearing status, DVT prophylaxis plan, wound care needs, PT/OT goals, anticipated length of stay, and post-SNF follow-up plans