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Many older adults leave hospital with complex discharge instructions and medication regimens that are difficult to understand and manage. When health literacy is low and discharge communication is rushed or unclear, older adults are at increased risk of medication errors, missed follow-up care, worsening symptoms, and delayed recognition of red flags.

This issue affects:

• Health outcomes: adverse drug events, falls, complications, deterioration, re-hospitalization

• Quality of life: anxiety, loss of confidence, reduced independence, caregiver stress and burden

Societal & system costs: increased ED volumes, hospital bed pressures, increased healthcare spending, and inefficient resource use related to avoidable return visits.

• Older adults (65+) experiencing polypharmacy, multimorbidity, and complex regimens

• Individuals with low health literacy

• Patients with cognitive impairment, memory challenges, frailty, or sensory limitations (vision/hearing)

• People with limited English proficiency or communication barriers

• Individuals with low socioeconomic status

• Those who are socially isolated or without reliable caregivers/family support

• People who lack consistent access to primary care or follow-up services

• Patients discharged after acute illness, surgery, or rapid discharges during periods of high system pressure

·       The immediate hospital discharge period, approx. 48-72 hours postdischarge, especially when discharge occurs quickly or unexpectedly

·       High-turnover environments where communication must happen rapidly (busy inpatient units, short-stay areas)

·       Patients discharged with multiple medication changes or new high-risk medications (e.g., anticoagulants, insulin, opioids)

Opportunities:

·       Discharge planning moments where teaching + confirmation of understanding can occur

·       Medication reconciliation and pharmacist involvement at discharge

·       Use of standardized patient-friendly discharge summaries, plain language med lists, and teach-back

·       Caregiver engagement at discharge and early follow-up

Linking patients to community supports

• Discharge is a vulnerable transition point

• Readmissions and ED visits are frustrating and sometimes preventable

• Patient understanding is frequently overestimated

• Workflows make it difficult to spend enough time on education

Stakeholder groups and typical mandates/capacity:

• Hospital teams (nurses, physicians, unit leaders): responsible for safe discharge, but are limited by time pressures, staffing, bed flow demands, and competing priorities.

• Pharmacists: strong interest and capacity to support medication reconciliation, teaching, and medication lists, but may be limited by resourcing or inconsistent integration at discharge.

• Primary care providers: want continuity and accurate medication lists but often receive incomplete information and have limited ability to see patients quickly post-discharge.

• Home care/community agencies: can support adherence and safety but depend on timely referrals and capacity.

• Patients and caregivers: may feel overwhelmed, tired, or unsure what questions to ask.

• Clear, respectful, plain-language discharge instructions

• Med lists that are accurate and easy to follow

• Consistent follow-up and reassurance after discharge

• Greater caregiver involvement when appropriate

• Better communication between hospital and community providers

• Increased system accountability so the burden doesn’t fall entirely on the patient

Community-at-large (especially families supporting older adults) often supports:

• More proactive discharge support and planning

• Improved navigation and understanding of what services exist

• Taking medications incorrectly (wrong dose/time, duplications, stopping early)

• Missing follow-up appointments or not booking follow-up at all

• Delayed help-seeking when symptoms worsen

• Not using available written resources (because they are confusing or inaccessible)

• Not engaging fully in discharge education due to fatigue, stress, or rushed discharge

• Not being present at discharge teaching

• Misunderstanding instructions themselves

• Being overwhelmed by responsibility and system complexity

• Inconsistent medication reconciliation processes

• Overreliance on written materials that are not health-literacy friendly

• Discharge teaching that is not standardized or not reinforced

• Lack of confirmation of understanding (no teach-back)

• Gaps in communication to primary care/community pharmacy/home care

Individual-level causes

• Low functional or critical health literacy

• Cognitive decline or memory impairment

• Language barriers and sensory impairments

• Anxiety, stress, and fatigue at discharge

Interpersonal-level causes

• Limited caregiver support or caregiver burnout

• Family members not included in planning or teaching

Organizational-level causes

• Discharge workflow pressures and limited staff time

• Variation in how discharge instructions are delivered

• Lack of standardized tools, scripts, or consistent expectations

• Fragmentation between teams (medicine, pharmacy, nursing, care coordination)

System-level causes

• Limited access to primary care follow-up

• Home care capacity constraints

• Inequities in social determinants (income, housing, transportation)

Protective factors

• Teach-back and repeated reinforcement of key messages

• Simplified medication summaries (plain language, large font, visuals)

• Post-discharge follow-up calls within 48–72 hours

• Pharmacist counselling and strong medication reconciliation

• Remote monitoring and virtual care supports (when appropriate)

• Strong caregiver involvement and community supports

• Existing discharge foundation processes already in place

• Staff who value patient safety and patient experience

• Many evidence-based tools already exist (teach-back, discharge bundles)

• Potential capacity for follow-up calls, pharmacy support, virtual care

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• Time pressure and staffing constraints

• Variation in discharge teaching quality across units

• Discharge information can be complex, inconsistent, or “too much at once”

• Communication gaps between acute care and community follow-up

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• Growing emphasis on reducing readmissions and ED pressures

• Momentum toward equity, quality improvement, and system sustainability

• Remote/virtual tools can support follow-up and reinforcement

• Partnerships with pharmacies, primary care, home care, PFAC

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• High patient volumes and ongoing health human resource shortages

• Competing organizational priorities and “initiative fatigue”

• Limited community capacity for follow-up services

• Risk of interventions becoming “extra work” instead of embedded workflow

• Standardized discharge summaries written in plain language

• Medication reconciliation programs (pharmacy-led discharge processes)

• Teach-back discharge education model

• Follow-up calls within 48–72 hours after discharge

• Caregiver inclusion policies and discharge planning supports

• Remote monitoring for high-risk populations when appropriate

• Quality improvement initiatives often include:

  • readmission reduction strategies

  • discharge pathway standardization

  • patient education toolkits

  • ED avoidance pathways (surgery clinics)

• Evaluation data

  • 30-day readmission rates

  • ED visits within 7–30 days

  • medication discrepancy rates

  • patient satisfaction / understanding measures surveys

Best available evidence suggests that reducing post-discharge harm and utilization requires both:

1. patient-level supports (health literacy + medication understanding), and

2. system-level changes that reduce complexity and improve follow-up.

Evidence-informed directions supporting your model include:

• Health literacy strongly influences safe self-management after discharge and impacts readmission risk.

• Teach-back improves patient comprehension and can reduce readmissions in chronic disease populations.

• Simplified medication lists and discharge summaries improve adherence and reduce confusion.

• Follow-up calls identify problems early and support safer transitions.

• Caregiver involvement improves understanding and continuity.

Equity-informed approaches are necessary because discharge safety is strongly shaped by access to supports and social determinants

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