From discharge to the next appointment
For care coordinators, discharge planners, clinicians and peer staff supporting adults leaving substance-use treatment. Help the person leave with a usable next step and a named contact when arrangements are unfinished.
Original workflow pilot, adapted from hospital discharge and communication guidance. Use alongside your service’s existing discharge procedures and adapt the coordination steps to the setting. This is not a complete discharge protocol, a legal checklist, a clinical assessment or an emergency-response plan. This adult toolkit does not cover pediatric consent or caregiver arrangements.
Use the plan you already have
AHRQ’s IDEAL framework includes the patient and family in planning, respects their concerns, and addresses home needs, medicines, warning signs, test results and follow-up. [2] This toolkit adds a small coordination step alongside your existing discharge process.
Start with My Discharge and Follow-Up Plan. Offer the shorter appointment card if the person wants the visit details in one place. Keep the clinical instructions and medication list available with it. Optional companions cover transport and caregiving, the first week after treatment, and support contacts.
Make one handoff concrete
AHRQ’s RED toolkit assigns discharge staff responsibilities for arranging follow-up, addressing attendance barriers, checking access to medicines, providing contact instructions and communicating with the receiving clinician. [1] The steps below are an original local workflow proposal.
- Choose the next step with the person. Ask: “Which part of getting to your next visit feels least settled?” Offer help reading or writing. Ask about language, format and access needs. Involve a supporter the person wants, using your service’s consent and safeguarding procedures. A declined worksheet does not mean declined care.
- Check with the receiving service. Verify acceptance, the appointment purpose, date, time, time zone for remote visits, location or connection instructions, and a callback number. Record who confirmed these details. An automated referral receipt alone is not a booked visit. Use approved channels for clinical information and record necessary handoff details in your usual system.
- Walk through attending. Ask about getting there and home, phone/video access, costs that need checking, work and caregiving. A video visit is an option only if the service offers it and it fits the care plan. Give an unresolved barrier an owner and a time to check back. If a clinical issue prevents a workable plan, bring it to the responsible clinician through your established process.
- Keep clinical tasks with the clinical team. Confirm that the person has their current medicine and urgent-help instructions, knows the clinical contact, and has a route for questions about obtaining prescribed treatment. Do not use this card to calculate a supply, change a dose or decide discharge readiness. Refer gaps to the responsible clinician.
- Agree on follow-through. Name the staff member who will check outstanding arrangements and who covers their absence. Agree how and when to reach the person and what can be left in a message. Follow your privacy procedures. Arrange a way to reconnect if the person has no reliable phone or private device.
Check the explanation and the take-away
AHRQ’s teach-back method asks people to explain the plan in their own words. It checks the explanation, not the person’s memory. They may use their handout. Clarify misunderstandings and check again. [3]
Original script: “Using your card, walk me through the next visit. What will you do if the ride falls through? Who will help with the part that is still unconfirmed? I want to check that I have made the next step clear.”
For paper, let the person find the visit and backup contact on their copy. For a completed PDF, save and reopen it together. For web notes, use the text download or print before closing. The editor does not send notes to AddictionHelp or save them automatically. Use fictional details for demonstrations and your organization’s procedures on shared devices.
Track what actually happened
Use these proposed labels in your existing workflow. Keep the appointment status separate from each unresolved practical task. A visit can be confirmed while transport is still unresolved.
| Status | What it means | Next action |
|---|---|---|
| Referral sent | A request went to another service. Acceptance and scheduling remain unconfirmed. | Named staff member checks the response. |
| Visit confirmed | The receiving service agreed to visit details and they were shared with the patient. | Check remaining access needs and the patient’s copy. |
| Care received | A patient report or permitted provider confirmation indicates the visit occurred. Record which source supports it. | Confirm who owns the next care step under the agreed plan. |
| Changed, declined or unknown | The appointment changed, the person declined it, or attendance has not been established. | Record the actual state. Offer an appropriate next step without assigning blame. |
When no one answers or a visit is missed, use your service’s agreed outreach and escalation process. Do not infer that the person is safe, has returned to substance use or no longer wants help. Discuss options when contact is made. This toolkit supplies no universal contact deadline or outreach schedule.
Fictional handoff: Alex’s Thursday visit is confirmed. The return ride is not. Coordinator Lee owns the transport question and will update Alex Wednesday by noon using the agreed number. If Lee is absent, the service’s designated covering staff member takes that task. The visit stays “confirmed”; transport stays “unresolved” until checked.
Evaluate the pilot with both groups
Use the patient/family and staff session guide with fictional details first. Ask patients or supporters to find the appointment, identify the unresolved ride, explain the backup and retrieve their saved copy. Ask staff to distinguish the referral from the booking and identify who acts when a coordinator is absent. Record assistance needed, confusing wording and any critical missing information.
Before any operational pilot, choose the observation period and eligible discharges. Track the number offered a card, accepting it, leaving with a confirmed visit, and having unresolved tasks with an owner. Record staff time and patient-reported usefulness. For attendance, report confirmed attendance, reported nonattendance, changed plans and unknown outcomes separately, with the source of confirmation. Keep denominators visible and avoid personal details in improvement summaries.
Compare the workflow with the service’s baseline and investigate missing follow-up data. These are proposed process observations, not a validated score or proof of causation. Downloads, completed cards and more bookings do not establish reduced relapse or better health.
Evidence and limits
The cited resources address hospital transitions and general communication. Applying their principles to an adult addiction-treatment workflow is an adaptation, not evidence that this exact toolkit is effective. The workflow has not been evaluated for patient outcomes. Use feedback from patients, families and staff to improve its fit.
- AHRQ: Re-Engineered Discharge, Tool 3. Hospital discharge responsibilities: appointment coordination, practical barriers, medicine access, contact instructions and handoff. Not a residential-SUD effectiveness trial.
- AHRQ: IDEAL Discharge Planning. Patient/family partnership, home needs, medications, warning signs, test results and follow-up. Hospital-to-home setting.
- AHRQ: Use the Teach-Back Method, Tool 5. Check staff explanation using patient own words, permit handout, clarify and repeat without shaming. No effectiveness estimate imported.