Inadequate coordination of patient discharges was named among the top 10 threats to patient safety in 2025, according to a recent report from ECRI and the Institute for Safe Medication Practices. Gaps in communication, follow-up and medication management continue to put patients at risk after they leave the hospital.
To strengthen discharge processes and ensure safer transitions of care, hospitals are deploying more proactive, interdisciplinary approaches — from virtual medication reconciliation to integrated navigation platforms and social determinants of health screening.
Becker’s recently asked three hospital and health system leaders to share one key strategy their organization is implementing to improve discharge coordination and reduce safety risks.
Their responses are featured below and are lightly edited for length and clarity.
Victoria Bhardwaj, DNP, RN. System Manager of Care Transitions; Mark Lockett, MD. Chief Quality Officer; and Jennifer Thorpe, DNP, RN. System Chief of Case Management and Care Transitions at MUSC Health (Charleston, S.C.): Providers customarily perform medication reconciliation during transitions in care, but adequate review at discharge is a challenge. Complex patients frequently have multiple medication changes during admissions. Failure to adequately explain medication changes can trigger avoidable readmissions, jeopardize patient outcomes, lower satisfaction and increase healthcare costs.
To address this issue, MUSC Health Charleston schedules telehealth medication reconciliation appointments for COPD and acute kidney injury patients. These patients have high morbidity and mortality risks and low medication adherence. Appointments are completed within 24 hours of discharge. By arranging these telehealth sessions before discharge and confirming accurate primary care provider details, MUSC Health expects to improve medication adherence, ensure timely follow-up post-discharge and lower readmission rates. MUSC Health partnered with their school of pharmacy to utilize volunteer pharmacy interns to conduct these appointments. The interns are eager to sharpen their skills and engage in real-time patient care, fostering a multidisciplinary strategy for smoother discharge coordination. The proactive approach ensures patients receive the coordinated support and monitoring they need.
By pinpointing and addressing medication knowledge gaps, healthcare providers can deploy targeted solutions like telehealth reconciliations to strengthen care coordination. This approach cultivates a safer, more supportive environment for patients across the continuum of care. The telehealth project sharpens inpatient care delivery and streamlines transitions to outpatient services. Through evidence-based practices, enhanced interdisciplinary communication and greater patient engagement, this initiative strives to improve care and avoid readmissions by ensuring medication compliance.
Jay Grider, DO, PhD. Chief Quality Officer at UK HealthCare (Lexington, Ky.): We are instituting an ambitious process ensuring clinical navigation from the inpatient admission to the ambulatory clinic setting called LINK (Local Integration of Navigation with Kentucky). This process coordinates previously dis-concordant care delivered by hospitalist, specialist and case workers in the inpatient settings with ambulatory access to primary and specialty care through a population health navigation care platform. We realized as a tertiary/quaternary academic medical center that, even though we receive more than 20,000 transfers from all over the region, our readmission issue and thus our top threat to patient safety was in navigating our local population into their [patient-centered medical home], be it at UK or one of our local partners.
Gena Lawday, BSN, RN. Chief Quality Officer at UVA Health-Northern Virginia and Culpeper: At the UVA Community Health hospitals, we are placing a strong emphasis on identifying and addressing social determinants of health as a key strategy to improve coordination at discharge. As healthcare providers, we recognize that non-medical factors — such as housing stability, access to transportation to and from follow-up appointments, and the ability to afford nutritious food and medications — play a critical role in patients’ recovery and outcomes after leaving the hospital. By integrating SDOH screening and follow up into our discharge planning process, we are able to more accurately identify potential barriers that could lead to readmissions or complications, and proactively connect patients with the resources they need to thrive once they return to their communities.
To enhance coordination, we are leveraging case management tools and EMR add-ons that analyze SDOH data, and then help connect patients with the appropriate community resources. This allows us to tailor discharge plans that go beyond clinical information, incorporating support for issues like medication affordability or caregiver access. By focusing on this more holistic view of the patient and their environment, we hope to not only improve outcomes but also empower patients with the support structures they need for long-term health.