I continue to recall the sense of relief while standing beside my uncle’s bedside. The monitors were buzzing with consistent rhythms; the surgical team was congratulating each other on a textbook procedure. By all clinical standards, he was a success narrative. The intervention succeeded. The pathology was resolved. He was deemed “stable.”

We regarded his discharge as a triumph. We believed that the packet of papers he held (filled with appointments, medication routines, and wound care instructions) was an adequate roadmap for his journey home.

We were mistaken.

Within a few weeks, my uncle returned to the hospital. The “successful” surgery was reversed not by a mishandled scalpel, but by a failure in communication. He had returned home to a world that didn’t converse in the hospital’s terminology. He couldn’t grasp the subtleties of his medication. He couldn’t manage the intricacies of his own recovery.

We addressed his condition flawlessly, yet we failed him in life.

This misfortune gave rise to a concept I now refer to as the “patient carryover crisis.” It represents the perilous, unspoken chasm that exists between clinical discharge and the patient’s living room. It is the instant when the high-tech safety net of the hospital disappears, leaving vulnerable individuals to traverse a tightrope of medical terminologies and complex care routines they are not prepared to manage.

The distinction between the “patient” and the “person”

In contemporary health care, we have honed our skills in treating the “patient.” The patient is a set of symptoms, a billing code, a group of vital signs, and a bed number. The patient is manageable. We have protocols in place for the patient. We have EMR checkboxes that confirm the patient received their discharge instructions.

Yet, we often overlook the “person.” The person experiences anxiety that clouds their memory. The person may possess a fifth-grade reading proficiency or encounter a language barrier that transforms our “plain English” directions into nonsense. The person goes home to a residence with stairs they cannot ascend, a refrigerator devoid of nutritious food, or a support network that is equally bewildered.

When we provide a packet of instructions to the “patient” and inquire, “Do you understand?” they will almost invariably nod yes. They nod out of fear, out of respect for the white coat, or out of a desperate desire to leave.

Accepting that nod as truth is where the system falters.

Transitioning from documentation to verification

The Department of Justice and CMS are increasingly scrutinizing “substandard care,” linking high readmission rates to a failure in delivering essential services. However, for those of us on the frontline, the concern isn’t legal; it’s ethical.

To resolve the patient carryover crisis, we must fundamentally transform our discharge philosophy from compliance to competence.

Documentation alone that we informed the patient on what to do is insufficient. We need to verify their understanding.

This necessitates the strict implementation of the teach-back method and Carryover Skills Training (CST). We must cease asking closed-ended questions like “Do you have any inquiries?” and begin posing gentle challenges: “Show me how you’ll prepare this insulin when you’re home,” or “In your own words, explain what symptom would prompt you to call 911.”

We need to design workflows that consider cultural nuances. If a dietary restriction clashes with a patient’s cultural staples, and we do not discuss alternatives, that patient will invariably prioritize culture over compliance. That isn’t non-compliance; it is our failure to engage the person.

The cost of the gap

Hospitals incur millions annually in HRRP (Hospital Readmissions Reduction Program) penalties due to this gap. Yet, the financial loss is minor compared to the degradation of human trust.

My uncle’s death served as a wake-up call that altered the course of my career. It showed me that the most perilous moment in healthcare isn’t necessarily in the operating room; sometimes, it’s the journey home.

We possess the technology to manage complex illnesses. We have the proficiency to perform miraculous surgeries. Now, we must cultivate the discipline to ensure that care transfers effectively.

Let us cease celebrating the discharge signature and begin honoring the verified carryover. Only then can we respect the person, not merely the patient.

Rafiat Banwo is a health care operational and transformational leader, visionary, and founder of the CATALYST Network, an initiative aimed at addressing her coined term, the “Patient Carryover Crisis,” and reducing preventable patient readmissions that result in penalties and risks for SNFs and hospitals globally through health literacy and workflow engineering. Her publication, The Patient Carryover Crisis, emphasizes this work. She can be contacted via her LinkedIn profile and the CATALYST Network Consults website.