Learning Objectives
By the end of this section, you will be able to:
- Describe the steps for discharge from a healthcare facility
- Understand the issues with patients leaving against medical advice
- Explain the process of discharge from home health agencies
Discharging a patient from a healthcare facility is the final transition point in a patient’s journey through the healthcare system, although there may be other points or stops in a patient’s healthcare journey. During admission, a healthcare plan is discussed and constructed, which is when the plan begins to come into focus; discharge is the part of the healthcare plan ensures that the patient has the education, knowledge, supplies, and necessities to maintain their health. Follow-up appointments, such as with the primary team, specialty doctors, rehab, and physical therapy (PT) and/or occupational therapy (OT), get arranged. A thorough and well-planned discharge plan helps the patient progress through the healing process as smoothly as possible. Discharge planning is also the first step in care coordination and a vital part of patient-centered care.
Discharge from a Healthcare Facility
Discharge from a healthcare facility has many layers and procedures. Inpatient doctors collaborate and give their approval that all necessary patient benchmarks have been met: Has the patient been transitioned to medications that are available and safe for them to take outside of an acute care setting? Are the patient’s vital signs stable or within normal limits for them? Does the patient have a place to go? Does the patient have the resources to either properly care for themselves or have someone care for them?
Specialty teams that have been consulted during the patient’s care must also agree that the patient is ready for discharge. For example, the renal/nephrology team may require the patient to attend hemodialysis; once the patient is able to tolerate outpatient dialysis, the team gives approval and arranges follow-up for the patient after discharge. The endocrine team may have concerns about a patient’s blood sugar management. The cardiology team may want to have the patient wear a heart monitor to watch for arrhythmias. If the patient has diabetes, a specialist may want to speak with the patient and family about glucose monitoring or skin and wound care. Dietary needs might need to be considered. Social work may need to get involved to ensure the patient gets the support they need. There are many aspects to consider when arranging discharge.
Guidelines for Discharge Planning
The importance of discharge planning cannot be understated. A readmission within thirty days of discharge can incur financial penalties for the healthcare institution, which includes reduced or no reimbursement for healthcare costs incurred (Patel, 2023). Yet, no formal standards exist for discharge planning. Successful discharge planning involves the patient and their family from the beginning; again, this is why discharge planning begins upon admission. The plan must be based on collaboration with all individuals involved, and depends on follow-up, ongoing guidance, and education.
Link to Learning
The Agency for Healthcare Research and Quality (AHRQ) has an excellent resource for healthcare providers for implementing discharge planning systems at healthcare facilities. It includes roles for all members of the healthcare team, rationales for each role, and tools to help implement the guidelines. Medicare also has a handbook for patients and their families to guide their involvement in the discharge process.
Interdisciplinary Team Decisions
From morning huddles to daily rounds, all members of the healthcare team discuss their patients. Nursing generally reviews the patient load on their floor as a unit before handing out assignments for the shift. For physicians and surgeons, this process is typically called rounds, and their action is called rounding. Rounds involve a brief recap of the patient from admission and the most recent update on their condition. This may occur in a huddle, similar to what nursing does, or the physicians may physically walk the unit to each patient room. Research shows that conducting rounds in front of the patient and their family increases their involvement and improves outcomes (Strathdee et al., 2023). Respiratory therapy (RT), PT, OT, pharmacy, and all specialists (such as cardiology and nephrology) review their patients within their discipline as well.
However, all these disciplines need to collaborate to benefit a patient. Consider a patient admitted for abdominal surgery. According to the surgical team and internal medicine, the patient needs acute rehabilitation. Social work says an assisted living facility is needed to accommodate those needs. The nurse also informs the team that the patient has expressed concern about their dressing changes once they leave rehab. The patient only trusts their daughter to change the dressings, but she lives two hours from the patient’s home and cannot come every day. Also, the patient is showing a lot of reluctance to the dietary changes that come with managing their diabetes despite nursing’s efforts to educate. Each of these issues is intertwined with the other. What can be done? Are there other learning materials that can be given to the patient? Can a nutritionist speak with the patient about ways they can incorporate their current diet into a healthier diet? Can social work help coordinate a wound care nurse to come help with the dressing changes on the days the daughter cannot come? Successful discharge planning depends on the effectiveness of these interdisciplinary team conversations and decisions.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Patient-Centered Care
Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.
Skills: The nurse will:
- Discuss patient needs and requirements for discharge by evaluating the patient’s health situation from the patient’s point of view.
- Value and appreciate the patient’s own knowledge and experiences regarding their health.
- Respect that the patient and their family may have different values regarding the patient’s health and preferences regarding their level of involvement in the patient’s care.
Knowledge: The nurse will:
- Include multiple dimensions of patient-centered care.
- Respect how different cultures, economic backgrounds, and ethnicities serve as foundations for personal values.
Attitude: The nurse will:
- Seek to enhance personal knowledge in all aspects of human diversity.
- Try to see healthcare needs through the patient’s eyes.
- Respect the patient’s expertise with their own healthcare needs and symptoms.
Characteristics of Effective Interdisciplinary Teams
An effective interdisciplinary team (IDT) in health care is much like any effective team in any profession. They should be cooperative, professional, respectful, thorough, and thoughtful. The team comes together with the same priorities for the patient, and the value comes from their different specialties, which lend different perspectives on the patient’s needs. The most necessary element of an interdisciplinary team is strong, competent leadership (Table 8.3). This can come from the doctors and surgeons or can be a collaboration with nursing and social work.
| Characteristic | Example of Behavior |
|---|---|
| Positive communication strategies | Communicate clearly and professionally. Show mutual respect for all members of the team. Respond in a timely manner to queries. |
| Appropriate skill combination | Ensure all necessary members of the team are informed. |
| Supportive team climate | Inform fellow team members when changes to the patient’s plan of care are made (do not assume they will see it in the chart). Be proactive and considerate. |
| Appropriate resources | Ensure necessary supplies are available, and/or specialists are available to provide their input. |
Leadership and Structure
Generally, the primary team is the one that leads the discharge discussion. This is the team that admitted the patient; perhaps it is the internal medicine team and they coordinate with specialty teams, such as cardiology, endocrine, or renal. Sometimes the patient is admitted under a specialty team such as cardiology. The patient may have an extensive cardiac history and requires cardiology’s management, or maybe they were admitted from their cardiologist’s office.
Once the primary team approves the patient for discharge, other members of the IDT begin their tasks to prepare the patient. Pharmacy looks at the patient’s medication list and ensures there are no duplicates; they may have questions or discuss issues regarding the patient’s medications with the doctor. A large burden of planning patient discharge often comes down to nursing and social work. Once the necessary elements the patient needs are confirmed, nursing implements the discharge plan, conducts the required education, and finds resources/staff/specialists to educate and inform the patient and their family. Nursing and social work may work together to ensure the patient gets their necessary supplies and medications.
Identifying Patient Needs
The type of needs a patient had when admitted to the hospital more often than not have changed, sometimes drastically, by the time they are to be discharged home. Needs such as pain management may have been addressed by the inpatient stay, but now a patient may require teaching and resources to manage a new health problem. Does the patient need to go to an LTAC facility, but there isn’t one close to where they live, or that takes their insurance? Is the patient newly diagnosed with diabetes and now needs to know how to test their blood sugar? Was a PEG tube placed, and now the patient’s family member requires teaching on how to set up the feeding pump? Does the patient need further education on diabetes management? Does the patient understand why they need to take their medications as prescribed?
These are just a few examples of the patient issues, needs, and planning/logistics problems that may arise upon discharge. Many of these issues are related to the patient’s health literacy, or their ability to learn how to understand and manage information and teaching about their medical condition (Centers for Disease Control and Prevention [CDC], 2023). Understanding what patients need upon discharge and their level of health literacy helps the IDT know how best to address those needs. PT teaches patients how to use canes or walkers to get around. OT teaches patients how to get in and out of cars, or how to shop at the grocery store without straining a surgical incision. Nursing (sometimes with help from pharmacy) teaches patients about new medications and potential side effects. Nursing may also teach about how to set up a feeding pump and proper care of a PEG tube site. Specialty educators such as a diabetes nurse educator may spend multiple sessions while the patient is in the hospital, teaching them how to manage their diabetes, how to take their blood sugar, how to dose their insulin, or how to follow a specialized diet.
Risk of Caregiver Role Strain
Caring for a chronically and/or critically ill family member can take an emotional and physical toll on a person. Anyone can become a caregiver to a loved one. A caregiver could be the teenaged children of a seriously ill adult or the ill adult’s older parents with health issues of their own. A caregiver could be someone caring for their spouse while simultaneously holding down one or more jobs and caring for children. Sometimes the caregiver does not have a network of family or friends to help with caregiving, which means the person is doing everything with no interruption or relief.
It is difficult to see someone ill, and the demands of caring for a sick individual can be overwhelming, especially if the caregiver is unprepared. Family should be assessed as caregivers well before discharge, and the resources of the family should be seriously considered when creating a discharge plan for a patient. Could the family need respite care, a temporary caregiver (sometimes a nurse or a patient care aide) who can step in and take over the patient’s care while the primary caregiver takes a break? Respite care can be for a few hours; sometimes it can be for a whole day or more.
Sometimes the lack of social support and community for a patient can make it difficult to ensure they have a successful discharge. What kind of care does the patient need? Do they need in-home care, a nurse to stop by, or a day-care facility for the patient to go to during working hours? In extreme cases, a patient may need to go to an LTC or LTAC facility because they need medical devices or care that no one around the patient is able to provide. The more nurses can address myriad aspects of a patient’s care, the better the patient will do after discharge.
Life-Stage Context
Caregiver Role Strain
Caregivers who are young, such as teenagers or adults in their 20s, or those with young children and families of their own can have a very difficult time coping with a new caregiver role. It can be difficult or frustrating to put personal needs aside and put someone else’s needs ahead of your own. Resources such as support networks, respite care, and psychological counseling are available to help ease potential caregiver role strain.
As healthcare providers, it can be hard to see patients and their loved ones go through such pressure. It is important to be respectful as well as thoughtful and imaginative in ways that nurses can help ease the strain of young caregivers. Thinking ahead to what a family with considerable caregiver responsibilities may need helps a lot.
Development of Patient Goals
Part of a patient’s recovery involves establishing goals for the patient to work toward, and how the healthcare team can help the patient achieve those goals. Sometimes goals can come spontaneously from the patient themselves: they want to attend a grandchild’s graduation, or they want to stop being on so much insulin. Nurses work with patients to translate goals into achievable statements. One way to help a patient articulate their goals is by using the SMART goal mnemonic (Table 8.4). When executed properly, SMART goals help patients articulate what they want to achieve and give them a plan to reach this goal in an effective manner.
| S Specific |
M Measurable |
A Attainable |
R Relevant |
T Timely |
|
|---|---|---|---|---|---|
| Definition | Add in as many details as possible. | Create a goal that is trackable. | Reflect on whether the goal is reachable. | Think about why this goal is important to you. | Keep yourself accountable. |
| Ask yourself . . . |
What will I do? Why and by when? |
How will I measure my goal? | Can I accomplish this goal within a certain timeline? | Does this goal align with my values and other goals? | By when do I want to accomplish this goal? How long will it take? |
| Example | I want to stop having to inject insulin every day. To do that, I have to get my blood sugar consistently under control, which my doctor says is less than 180 two hours after eating. To get my sugar under control, I have to improve my diet, which means I need to eat more vegetables and fruits, and cut back on processed foods. | My blood sugar after meals must be checked with my glucometer and should be less than 180 two hours after eating. I will check my sugar as directed by my doctor and keep a record of my results. | The changes I need to make to achieve this goal are also changes that will make me healthier in the long run, so outside of this goal it is a good choice for my overall health. | Being a healthier person will help me live a longer and better life. | Change doesn’t happen overnight, but in six months I would like to see my blood sugar consistently at 180 or less when checked two hours after eating. |
Putting goals together often becomes an interdisciplinary and collaborative process because the patient’s baseline level of function, their support system, and their financial and community resources all need to be taken into consideration.
Link to Learning
The National Lipid Association’s resource sheet for clinicians on helping patients make SMART goals is helpful because lifestyle modifications are some of the hardest modifications to make. This resource is very clear and offers tips on how nurses can help patients to name and reach realistic goals.
Patient Education
Making SMART goals goes hand in hand with patient education about their health and their health literacy, which is a person’s ability to learn and utilize information and resources regarding their health in order to make educated decisions (CDC, 2023). Nurses help patients increase their health literacy.
Determining how best to provide the patient with the necessary educational resources is part of the nurse’s job. Ask the patient how they like to learn. Some patients are visual learners, so diagrams and handheld/tactile teaching materials are the best. Others prefer to read their information but perhaps do not have an appropriate literacy level for the materials available. Collaborate with the patient to figure out the best way they understand their health. One technique, often used in nursing and medical schools, is called “See one, do one, teach one.” For example, to prepare for discharge, the patient or family member may watch the nurse make a dressing change, then do one themselves with supervision, and then do one on their own. This teaches the patient how to care for their own medical needs after they leave the healthcare facility.
Link to Learning
This video provides details about the teach-back method for teaching others.
Established rapport with patients and their family members aids in educating patients and improving their health literacy. Communication should be easier because patients will feel comfortable asking questions. The key to patient education is teaching them to take ownership of their health.
Teaching and Evaluation of Discharge Plan
Nurses review discharge orders with the patient and their family member or designated learner. The designated learner is the person, either the patient, someone chosen by the patient, or a family member, who receives the education necessary for the patient’s discharge plan. All the discharge plans are summarized in the discharge summary, which is usually a formatted printout from the patient’s chart that reviews the patient’s reason for admission, the medications they were on before admission and the ones they are on currently, and scheduled appointments for follow-up (Figure 8.9). Pharmacy or the doctor often reconciles the medications beforehand to ensure all medications and dosages are correct and there are no duplications. Nurses may also check in with case management to ensure that all the medications on the discharge plan are going to be obtainable by the patient or covered by their insurance. The discharge plan also discusses any specific instructions the patient may need, such as how to make dressing changes, directions on wound care, caring for lines and drains, and instructions for follow-up as an outpatient. All members of the IDT collaborate to create the discharge plan, and because nursing is most often the last to be face-to-face with the patient, nurses must ensure the plan is clear, and if not, find ways to help clarify the discharge instructions. Nurses can remind patients that most discharge instructions will also be included in the online patient portal for easy access at a later time.
After the nurse reviews the discharge plan with the patient or designated learner, any necessary teaching must take place. Teaching can cover a wide array of topics, from explaining how to perform tasks such as wound dressing changes, monitoring vital signs at home, or explaining new medication regimens or diets. Discharge teaching must be documented in the patient’s chart and include what and how something was taught, as well as how evaluation of the learning took place. Most facilities conduct follow-up surveys via phone call or questionnaire to evaluate how effective the transition from discharge is. Follow-up surveys usually discuss the patient’s hospital stay, the discharge process, and any recommendations for improvement. Getting feedback from the patient’s perspective is always encouraged when making process improvements.
Leaving Against Medical Advice (AMA)
Sometimes, the plan of care created with the medical team during an inpatient or hospital stay does not coincide with patient expectations. If this is the case and the patient no longer wishes to receive care from the healthcare facility or provider, the patient may decide to leave without the doctor’s approval and a formal discharge, known as leaving against medical advice (AMA). If a patient insists on leaving AMA, it is the duty of the nurse and staff on duty to ensure the patient is fully informed regarding the risks of leaving AMA, and if they insist on leaving, that they leave as safely as possible.
Patient’s Right to Leave AMA
Treatment is always with patient consent, so if a patient has problems with the planned course of treatment, they are under no obligation to continue with it. The medical team can work with the patient to educate and reassure, or to reevaluate the plan depending on the patient’s needs and preference while keeping the patient’s best interests at the center of the discussion. However, if the medical team and the patient cannot come to an agreement, the patient may leave the hospital or healthcare facility AMA. Legally, in most cases, the patient cannot be compelled to stay for treatment they do not want, and they always have the right to leave AMA. If a patient insists on leaving AMA, there is a form to sign for hospital records. This form acknowledges that the patient was told they are not ready to leave the hospital, and that they have been advised that leaving can be detrimental to their health (Figure 8.10). It is preferred that patients sign the AMA form but not required.
Patient Conversations
Turning a Difficult Conversation into an Opportunity
Scenario: Joseph is a 65-year-old male who is housing insecure. Joseph also has diabetes and has a very hard time controlling his blood sugar and diet largely because of his housing insecurity and learned behaviors from that insecurity that he has gained over the years. Joseph was picked up by the police two nights ago for sleeping on the street and brought to the hospital after he showed signs of severe hyperglycemia. Joseph also has long-term damage from his diabetes, including impaired vision and peripheral neuropathy (nerve damage). Today, he is very angry with his nurse, Jason, because he does not want to adhere to the diet he has been prescribed.
Patient: This is ridiculous! I want what I ordered for lunch! What is this garbage?
Nurse: Unfortunately, Joseph, you cannot have what you ordered for lunch because it will make your blood sugar skyrocket. You ordered a hamburger, a grilled cheese sandwich, potato chips, and extra ice cream. This is not part of your diet and will make you feel sick.
Patient: Yeah? So? It’s what I want and I’m just going to eat it when I leave. Maybe I should just leave now so I don’t have to listen to your stupid face tell me these stupid things about my blood sugar.
Nurse: We are only trying to help you feel better, Joseph. You were feeling pretty terrible when you were admitted two nights ago.
Patient: Yeah, that’s true. But I didn’t ask to come here. I didn’t ask for any of this. You know what? Forget this. I’m out.
Nurse: What do you mean “I’m out?” Can you be more specific?
Patient: I mean I’m OUT. I’m LEAVING.
Nurse: Well, I can talk to the doctor, but I don’t think you’re ready to be discharged yet. Your blood sugar is still very high. At the last check it was over 300.
Patient: Didn’t you hear me? I don’t CARE. I want to leave because I hate this place.
Nurse: It is your right to leave whenever you want, Joseph. But if you leave, you know you aren’t going to feel better. You may get to eat the food you want, but after that you are just going to feel worse. I’m trying to help prevent you from feeling that way.
Patient: …
Nurse: Staying with us can only help you feel better. And if you feel better and learn the ways that you can stay feeling better, maybe you won’t have to be here as often. Will you consider it?
Patient: [grudgingly] Maybe. If I do want to leave, can I just leave?
Nurse: I hope you don’t, but if you insist, yes, of course, you can leave. I would appreciate it if you’d let me know if you are going to leave, though. I’ll bring you a paper to sign that says that you are leaving against medical advice (AMA). Once you sign it, you are free to leave if you wish.
Patient: Really? I just have to sign a stupid paper. That’s it? Why do I have to sign anything then? You aren’t going to arrest me?
Nurse: No, of course not! As a patient you have every right to refuse care. The paper is just for our records to show that you made your own decision to leave. I’m just trying to explain to you the reasons for your care decisions, and why it is better for you if you stay. Maybe if you understand why you’ll be more willing to try our ideas?
Patient: Maybe. Can I have a snack and some soda pop while I think about it?
Nurse: Sure, no problem. Thank you for considering, Joseph.
[The nurse leaves the room and goes to the kitchen to get Joseph a package of saltines and some sugar-free ginger ale. He pours the ginger ale into a pitcher with some ice and brings it back to Joseph with a cup and the crackers.]
Scenario follow-up: Jason explains what AMA means to Joseph calmly and professionally. He knows that he may not change Joseph’s mind, but he is giving him the tools he needs to make the decision for himself.
Mental Capacity to Leave AMA
There are, of course, exceptions to leaving AMA. These exceptions can include the patient not having the ability to make that choice for themselves. Perhaps they are not fully oriented—they don’t know their name, where they are, or the date—or their departure is impossible or incredibly unsafe (such as the patient is in critical condition and connected to lifesaving medications or machines). Sometimes, a patient may be a direct threat to themselves or someone or something else. In those instances, documentation by the nurse and treatment staff is important. On occasion, security services may be warranted to ensure the safety of the patient and staff. In extreme cases, a patient may be detained under a mental health hold to ensure their safety and the safety of the people that will be around them outside the healthcare facility. In general, however, most patients are legally decisional and can decide to cease treatment and leave at any time. Nurses must document the patient’s mental status and any interaction with the patient regarding the patient’s desire to leave AMA.
Clinical Judgment Measurement Model
Analyze Cues: What Are Some of the Advance Warning Signs of an Impending AMA Departure?
Observant staff can usually pinpoint warning signs and behaviors that indicate the potential for a patient to leave AMA. This can include anger, agitation, combative behavior, and outright threats to leave the hospital. Constant arguing with nurses, doctors, and staff can also be a sign. Overt signs can include the patient physically dressing to leave or packing their belongings. Reasons for leaving AMA can include frustration with the plan of care often because the patient feels their needs are not being met and requests are not being heard. Other examples include family or work obligations. Sometimes this may also come in the form of requests for second opinions or referrals to alternate healthcare facilities. Remember, in these situations, safety is paramount—safety of the patient, safety of other patients, and safety of the staff and healthcare personnel around the patient.
Interventions to Avoid Leaving AMA
Empathetic, therapeutic communication is a key part to preventing an AMA discharge. Therapeutic communication is the use of both verbal and nonverbal clues to communicate with another person. It is the nurse’s job to try to find from where the patient’s dissatisfaction stems. Is the patient confused about what the medical team is saying? Is fear or anxiety a root cause of their dissatisfaction? Sometimes a patient threatening to leave AMA is just frustrated because they are in pain, or they felt their questions were not answered adequately. Leaving against medical advice (AMA) puts the patient at risk for adverse outcomes. Healthcare providers and nurses mitigate these risks as much as possible before a patient leaves the hospital by being thorough and detail oriented and using therapeutic communication skills. Many nurses are now trained in forms of conflict resolution and nonconfrontational methods of defusing potentially volatile situations.
Health care is a dynamic profession that changes with every patient encounter, and as frontline healthcare providers, nurses are the first to identify a patient situation as well as potential ways to address the issue. Does the patient understand the treatment plan? Does the patient understand what may happen if they leave before the doctor says they are ready and safe to leave? Sometimes, a patient’s dissatisfaction can be resolved by getting a different healthcare provider (another doctor, nurse, or social worker) to speak with the patient to try to encourage them to stay.
Nursing Documentation for AMA Discharge
Documentation of an AMA discharge is very important because of the risks of leaving AMA. Thus, it is incredibly important for nursing to properly document the AMA departure. While it isn’t an absolute necessity, it is helpful if the patient signs the AMA form. Otherwise, the nurse should enter a progress note into the patient’s chart documenting the issues and conversations leading up to the AMA discharge. These documented notes can ultimately be subpoenaed and used in court, so it is important to be factual, professional, and clear.
Leaving AMA means the patient’s medical condition continues to be untreated or inappropriately addressed. This can lead to a worsening of the problems that got the patient admitted in the first place and can ultimately lead to increased mortality. If at all possible, attempt to give the patient at least some of their discharge instructions. Leaving AMA with unresolved medical issues also affects the hospital/healthcare facility. Depending on the severity of the issues, the patient may be readmitted soon after the discharge, and it is possible the facility will not be fully reimbursed for the costs of the patient’s care. Ensure that all documentation of the patient’s care and the situation surrounding the AMA discharge is complete and professionally written.
Discharge from Home Health Agencies
A home health agency (HHA), or a service that provides medical care in a patient’s place of residence, has strict rules regarding the discharge process. Often, patients need additional medical care but not enough to stay admitted to an acute care facility. Instead, HHAs are utilized. HHAs provide a full range of services, such as food preparation, assistance with hygiene, wound care, and medication setup. Nurses also complete weekly or biweekly assessments to monitor for decline or improvement in health status. Nurses working for HHAs develop individualized schedules for each patient based on the discharge orders and services needed, but can also serve as an on-call healthcare professional to provide an assessment to determine if a trip to the hospital is warranted. The HHA nurses have instant communication with the provider caring for the patient, which allows for needs to be met in the comfort of the patient’s residence. Most patients are approved for a sixty-day or thirty-day period of care.
Discharge from an HHA takes place when all treatment goals of the plan of care have been met. For discharge from an HHA to occur, an admissions RN must reevaluate the patient. In this meeting, all discharge teaching and an evaluation of the patient’s response to learning must be documented in a timely manner. If determined goals have been met, the patient may be discharged from the HHA’s services, but just as in an acute care facility, if the patient’s condition changes, they can be readmitted or have the current plan extended if needs are identified.
Life-Stage Context
The Importance of Being Clear: Home Health Agency Discharge
When discharging an older adult from an HHA, it is imperative that discharge teaching be done just as if the patient were leaving an acute care or extended care facility. Learning needs must be assessed. Does the patient tend to get confused or forgetful? Does the patient fully understand the medications they are taking and when they should take them? Is the patient’s living space safe for them without home health monitoring? Sometimes it is appropriate for a secondary learner to be present when doing discharge teaching to ensure a caregiver also understands what needs to be done and how to do it.