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'Ticket to Home' tool helps patients and families prepare for discharge


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‘Ticket to Home’ tool helps patients and families prepare for discharge

After reading this article, you will be able to: 

  • Demonstrate how to use the “Ticket to Home”
  • Explain how discharge preparation prevents readmissions 

The case management department at Children’s Healthcare of Atlanta (CHOA) developed a tool called “Ticket to Home” to prepare patients and their families for discharge. The tool also helps the care team communicate what goals they need to meet before the patient can go home. 

The genesis

CHOA staff realized they needed to improve the hospital’s discharge process when they reviewed the results of a Press Ganey patient survey. Several respondents indicated that they felt unprepared upon discharge, says Marcia Seay, RN, CCM, manager of CHOA’s case management department. 

The inadequate discharge preparation problem is not exclusive to CHOA—it’s a nationwide issue, says Stefani Daniels, RN, MSNA, CMAC, ACM, managing partner at Phoenix Medical Management, Inc., in Pompano Beach, FL. In fact, one of the hottest issues in healthcare—preventable readmissions—can be traced back to poor discharge preparation, Daniels says.

To improve discharge preparation, the CHOA interdisciplinary team met for a three-day workshop to develop a solution. The team members that attended the workshop blamed poor communication for their patients’ lack of preparedness at the time of discharge. Their solution: a laminated guide they dubbed “Ticket to Home.” (See a sample ticket on p. 8.)  

The ticket 

The ticket is a laminated piece of standard-sized paper, divided into four sections:

  1. Treatment goals that your child must meet in order to go home
  2. Things to help you prepare for going home
  3. Classes for you to take before going home/discharge 
  4. Things for you to learn about before going home/discharge 

Each section lists several items with checkboxes for “needed” and “completed.”

The physician assesses the patient within 24 hours of admission. Based on that initial assessment, the physician communicates the patient’s needs using a dry-erase marker to mark the ticket appropriately. 

For example, if the patient is on oxygen, the nurse or physician will mark the needed box next to the appropriate goal. When the patient’s condition has improved so that he or she no longer needs oxygen, the nurse will check the completed box to indicate that goal was met. 

Once all the care checks are fulfilled, that patient is ready to go home. After the physician discharges the patient, the staff wipes the ticket clean so the team can use it for the next patient. 

Communication with patients and families 

When parents are not prepared for a discharge, it can cause delays, Seay says. If both parents are working and don’t expect their child to be discharged, they might not be able to pick up their child in a timely fashion. 

The ticket allows physicians and nurses to update patients’ families on their child’s condition. If parents can’t be by their child’s bedside all day, they can check the ticket to see whether anything has changed since their last visit. 

This is especially helpful because CHOA switched to electronic charting in May 2008. Parents do not have access to the documentation contained in the electronic system. 

In addition to keeping parents updated on their child’s condition, the ticket indicates what education or training they need to accomplish before their child can go home, such as CPR training or cast care. 

Communication with nurses and physicians 

The ticket improves communication among the interdisciplinary team. For example, at the end of a shift, a nurse might forget to tell the next nurse a portion of the care plan. With the ticket, every member of the care team can see what each patient needs and which needs have already been met. 

The ticket also allows physicians to keep track of case management, nursing, and social work interventions without having to access the progress notes area of the electronic record for every discipline. This prevents team members from repeating training that the patient or family has already received. 

Lessons learned 

CHOA piloted the Ticket to Home program in a few select units, and the case managers and physicians learned quickly that the ticket doesn’t work for every patient, Seay says.

For example, patients that only stay overnight after a surgery will not benefit from the ticket because they are discharged so quickly after admission. So CHOA case managers use the ticket for patients that stay for more than three days. 

They also learned that the tool needed to be modified to apply to patients with more serious conditions. Patients with certain chronic conditions, for example, may never breathe normally, so instead of a goal that says “breathe normally,” the goal will say “breathing treatments decreased to every _____.” In fact, many units have tailored the ticket to apply to their patient population, Seay says.

The technology-dependent unit (e.g., patients who require ventilators) customized the form to meet its educational needs. Parents are able to see that they need to change the trach twice before they can go home, Seay says.

Seay and Daniels agree that case managers in other settings could use the Ticket to Home program. 

For example, people with elderly relatives in the hospital can visit in the evening and check the ticket to see what the care plan is or prepare for when their relative is ready to go home, Seay says.

“Any tool that doesn’t add additional burden on the case manager and in some way codifies the instruction advice and counseling that the clinical team is responsible to do has to be beneficial,” Daniels says.