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In this issue of BMJ Quality and Safety, Greysen and colleagues present results of a large, multi-institutional interview study of readmitted patients’ perspectives of post-discharge care.1 Investigators interviewed over 1000 patients while they were readmitted to one of 12 academic medical centres and asked them a variety of questions about barriers to recovery after their previous discharge. More than half of patients reported difficulty carrying out the care plan given to them when they were first discharged from the hospital, even though the vast majority reported no difficulties understanding what they were supposed to do.
Post-discharge self-management can be conceptualised as a three-legged stool comprised of knowledge, planning and ability. The patient needs to know what to do (for instance, take a medication three times a day). The patient also needs to have a plan for how to do it (for instance, use a pill box with three slots per day; fill it accurately on a weekly basis; use a reminder system to signal time for medication). And crucially, the patient has to be able and willing to carry out that plan (for instance, buy the medication and pill box; have some help if needed filling it; …