A 79-year-old man has a complicated surgery as part of his cancer treatment. The surgery seems to go well; he recovers in the ICU, but is there for 12 days after developing pneumonia. He eventually transitions to a regular inpatient bed. A day later, the case manager calls one of the man's daughters to say that they'll be discharging him.


The daughter rushes to the hospital, a well-regarded academic medical center, to help prepare her father for the transition home. While briefly going over a scant list of instructions, the discharge planner does not tell the daughter that Bob will likely require 24-hour supervision for a couple of weeks. She's told that a visiting nurse will stop by a couple of times a week. The family will have to give Bob overnight tube feedings for at least several days. Despite having good vitals, Bob is still weak. He's also somewhat disoriented and is exhibiting signs of postoperative delirium. During the months leading up to surgery, no one explained the complexity of post-surgical care to the family, none of whom has any medical training and all of whom work have families of their own.

At home, family caregivers sit by Bob day and night, helping with feedings, managing his anxieties and confusion, cleaning him, flushing his feeding tube. Bob's condition isn't getting better. The confusion persists. He coughs up phlegm. He's eventually taken off of the feeding tube but has trouble keeping all his food down. There's concern he isn't getting enough nourishment.

About two weeks pass and the family's concerns mount. Having received unsatisfactory responses from the surgeon, the family turns to Bob's primary care physician, who has been out of the loop since Bob went in for surgery. The doctor admits Bob to a community hospital. While there, they discover that Bob is severely dehydrated and that a complication is preventing him from properly digesting food. The hope is that Bob will eventually recover at the hospital, and be transferred to a rehab or skilled nursing facility where he can regain his strength and learn how to follow a care management plan.

That's the hope.

This story isn't unique. Untrained family members are continually being asked to turn into caregivers, often with little notice and time to adjust their life schedules. For my family, this ordeal has been playing out for weeks. "Bob" is my father in-law. His situation has turned our lives upside down.

We dedicate a lot of space in H&HN and H&HN Daily to the topics of accountable care and care coordination. A great deal of the conversation centers around better communication between providers, but we can't lose sight of the family and patient in all of this. By some estimates, nearly 30 percent of the population serves as a caregiver for a family member during a given year, "spending an average of 20 hours per week providing care for their loved one." And the costs are staggering: nearly $375 billion a year.

We can't talk about care coordination without mentioning discharge planning. As the Family Caregiver Alliance notes, "there is a surprising lack of consistency in both the process and quality of discharge planning across the healthcare system." But there are solutions. Projects sponsored by AHRQ, IHI and others have shown that improved communication between doctors, nurses, case managers and family members can have a dramatic impact. A study in the July 25 issue of the Archives of Internal Medicine found that "when hospital discharges are well executed, hospital staff members provide timely and accurate health information to downstream providers at patient discharge and activate patients and their caregivers to manage their care. Focusing on good cross-setting communication at the time of hospital discharge can improve health outcomes, decrease health care costs, and support patients in understanding how, when, and where to seek help, should they need it."

The study looked at Medicare patients from six hospitals in Rhode Island between Jan. 1, 2009 and June 30, 2010. Patients in the control group worked with coaches to prepare them for self-management and to communicate more effectively with providers. Coaches visited patients in their homes and conducted follow-up phone calls. Granted, this goes beyond providing adequate instruction at discharge, but the study resulted in a 30 percent drop in 30-day hospital readmissions. As the authors note: "This finding underscores the opportunity to improve health outcomes beginning at the time of discharge in open health care settings."

Matthew Weinstock is the senior editor for Hospitals & Health Networks magazine. Email your thoughts to mweinstock@healthforum.com.