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The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has published Recovery Beyond Survival, a review of the quality of rehabilitation care provided to patients following an admission to an intensive care unit. Based on 1,018 patients aged 18 and over who were admitted as an emergency to an ICU for four or more days between 1st October and 31st December 2022 (and who survived to hospital discharge), this report covers a range of specialities and ward areas, and identifies areas for improvement. Themes that emerge include the need for co-ordinated multidisciplinary care and good communication between professional groups, patients and their families. It also contains examples of excellent practice, such as early assessment for rehabilitation, the setting of short-term rehabilitation goals, the use of patient diaries, providing a leaflet on discharge with information about the availability of ongoing support, and the provision of follow-up appointments with the critical care team. This report goes on to make recommendations to support national and local quality improvement initiatives: Improve the co-ordination and delivery of rehabilitation following critical illness at both an organisational level and at a patient level. Develop and validate a national standardised rehabilitation screening tool to be used on admission to an intensive care unit. Undertake and document a comprehensive, holistic assessment of the rehabilitation needs of patients at risk of morbidity. Ensure that multidisciplinary teams are in place to deliver the required level of rehabilitation in intensive care units and across the recovery pathway. Standardise the handover of rehabilitation needs and goals for patients as they transition from the intensive care unit to the ward, and ward to community services. Provide patients and their family/carers with clear information.

This paper identifies some of issues around transitions of care when a patient leaves an intensive care unit (ICU) for ‘a general medical ward (or other de-escalated care settings, such as a step-down unit) for observation, treatment, and discharge planning.’ The authors describe a checklist to support safe ICU transfers of patients to medical wards or step-down units.  The proposed 7-step checklist has the mnemonic SIMPLER: Stable vital signs Intact aeration Medications reviewed Prepared psychology Lingering catheters Extreme laboratory findings, and Return plans. The authors state: "The first 3 steps are prerequisites in a medical ward and denote the importance of stable vitals signs, intact aeration, and a diligent medication check. The next 3 steps are priorities in the ICU and involve determining patient expectations, managing catheters or other devices, and reviewing laboratory results. The final step concerns contingency plans for unforeseen deteriorations and goals of care."

Managing insulin during care transfers requires improvement. Understanding factors that impact insulin management during this process improves the likely effectiveness of interventions. This study aimed to map the processes involved in managing insulin during transfers of care and the factors that affect them to identify potential areas for safety improvement interventions.

In June 2023 the Secretary of State for Health and Social Care announced that HSSIB would undertake a series of investigations focused on mental health inpatient settings. This overarching report brings together and explores cross-cutting patient safety risks across five individual investigations. The aim of this report is to examine patient safety risks identified across the following HSSIB investigations: Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning (12 September 2024) Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings (24 October 2024) Mental health inpatient settings: out of area placements (21 November 2024) Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (12 December 2024) Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge (30 January 2025) Findings Safety, investigation, and learning culture There remains a fear of blame in mental health settings when safety events happen. This contributes to a more defensive culture despite staff actively wanting to learn. Many recommendations to support learning for improvements in mental health care do not lead to implemented actions. Reasons for this include a lack of impact assessment resulting in unintended consequences, no clear recipient involved in the development of recommendations, and duplicated recommendations across organisations. System integration and accountability The integration of health and social care within an integrated care system currently relies on relationships, with an expectation and hope that they will work well. However, where this is not the case, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness. The delivery of care for people with mental illness and severe mental illness is challenging because health and social care services are not always integrated and their goals are not always aligned. Physical health of patients in mental health inpatient settings There are gaps in the provision of physical health care for people with severe mental illness, including inconsistent health checks, poor emergency responses, and misattribution of physical symptoms to mental illness. The misattribution of physical symptoms to patients’ mental health was observed and had the potential to contribute to worsened patient outcomes. National reports, strategies and research have made recommendations to improve the physical health of people with severe mental illness. However, there is evidence that recommendations are delayed in implementation and people continue to die prematurely. Integrated care boards lack the required data and the necessary analytical capability to assess disparities in access, experience and outcomes related to the physical health needs of people with severe mental illness. There is variation in how the physical health checks are carried out on mental health inpatient wards, with limitations in processes for following up on patients’ physical health needs. There is variation in the knowledge, skills and experience of staff who undertake physical health checks and in the environments in which these checks take place. Patients may not always be supported in terms of health education about their physical health risks and modifiable risk factors, for example smoking, dietary advice and physical activity. Caring for people in the community Integrated care boards cannot consistently draw reliable insights from data at national, system or local level, to optimise and improve services, patient care, and outcomes across mental health pathways of care. This results in variability in service provision which does not always meet the needs of individual patients or local populations. Inpatient ‘bed days’ are taken up by people who no longer need them, because people who are clinically fit for discharge are delayed in being transferred to their home or a suitable residence (appropriate placement). Reasons for delayed discharges include issues with housing support and establishing suitable accommodation. This means patients are not always in the right place of care. Barriers to discharge affect patient flow and may result in delays in admission for people with severe mental illness. This means they have to be cared for in a community setting while waiting for an inpatient bed. There is variation across the country in how drug and alcohol services are provided. The variation does not allow for fair and equitable treatment for all patients. Community services are vital to support people to stay as well as possible and to prevent hospital admissions. However, there is variation in community service provision across the country. Staffing and resourcing Staffing and resource constraints in inpatient and community mental health settings impact their ability to provide safe and therapeutic care. In inpatient settings, constraints contribute to mental health wards aiming to staff for ‘safety’ but not always for ‘therapy’. Challenges for staff include the emotionally demanding nature of their work; this can lead to staff burnout and sickness, and further strain on services. There are gaps in mental health workforce planning, particularly in community services where there is no evidence based workforce planning tool to support a standardised staffing establishment setting model. Digital support for safe and therapeutic care A lack of interoperability or integration between digital systems affects the provision of care across mental health, acute and community providers. Challenges in securing appropriate funding impacts on the ability of hospitals to integrate and update their digital services and infrastructure. Electronic patient record functionality is often not available or does not meet staff needs, and so it is not used. Examples include absent functions for food and fluid balance monitoring and risk assessment of venous thromboembolism (blood clots). Challenges in providing and maintaining patient-facing technology, for example televisions and payphones, impacts on the therapeutic environment and the ability of patients to maintain contact with families and loved ones. Where technology for monitoring patients had been introduced, implementation has required considerations to ensure it is used appropriately, is patient-centred, maintains therapeutic engagement, and supports patients to feel safe. Suicide risk and safety assessment ‘Doing’ tasks, like ‘ticking’ checklists, overshadow meaningful, empathetic ‘being’ interactions with patients. Open, compassionate conversations that build trust and therapeutic relationships, enabling patients to own their risk while feeling supported, can help mitigate this. Investigation processes can contribute to a fear of blame, and subsequently contribute to defensive practices such as checklists and a ‘tick box’ culture. This inhibits open and honest conversations and the ability to put the patient, as their authentic self, at the heart of them. Safety recommendations HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations. This may help the Department of Health and Social Care understand what has worked when implementing actions from recommendations and enable learning about why some recommendations have not achieved their intention. HSSIB recommends that the Secretary of State for Health and Social Care directs and oversees the identification and development of a patient safety responsibilities and accountabilities strategy related to health and social care integration. This is to support the management of patient safety risks and issues that span integrated care systems. Safety observation National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and therapeutic care.

This study in the Journal of Patient Safety aimed to determine the incidence and types of adverse events (AEs) in patients transitioning from the emergency department (ED) to the inpatient setting. A second objective was to examine the risk factors for patients with AEs. The authors found that AEs were common for patients transitioning from the ED to the inpatient setting. They conclude that further research is needed to understand the underlying causes of AEs that occur when patients transition from the ED to the inpatient setting. Understanding the contribution of factors such as length of stay in the ED will significantly help efforts to develop targeted interventions to improve this crucial transition of care.

This is the second in a series of reports by the Health Services Safety Investigations Body (HSSIB) on the theme of healthcare provision in prison. The first investigation focused on the delivery of emergency care. This investigation looks at improving patient safety in relation to continuity of care for patients detained in prison. In the context of this investigation, ‘continuity of care’ means maintaining a patient’s healthcare throughout the prison system regardless of their location. The investigation considered the movement of patients between prisons, to and from court, and on release. It also looked at patient attendance at appointments for internal primary care services and secondary care outpatient appointments. Findings of this report include: ‘Did not attend’ (DNA) rates for outpatient appointments for patients in prison during 2024 were high, at 52% and 57% for males and females respectively. This compares to a DNA rate in the general population of 26% for both sexes. Female prison patients are often taken to outpatient appointments by male prison officers or a mix of male and female officers. This can affect the patients’ decision making about whether to go or not, particularly for appointments that are for sensitive female clinics such as obstetrics and gynaecology. The use of telemedicine in prison healthcare has declined since the end of the COVID-19 pandemic and it is used rarely in comparison to face-to-face appointments. Telemedicine has the potential to reduce the burden of prison officer escort duties for outpatient appointments (which costs £48m to £50m per year), increase the number of outpatient appointments available per day to patients in prison, and reduce the number of appointments that patients refuse to go to. Patients in prison may not attend pre-arranged appointments because of a lack of information about the appointment caused by privacy and security issues. For example, they may not be informed about timings, the nature of the appointment, or the health reasons and importance of attending. This means they are not able to make an informed decision about their health and whether they want to attend or not. Patients in prison are more likely to miss outpatient appointments than patients in the community, due to the prison regime and logistics beyond the control of the patient. Prison healthcare departments rely on relationships they have developed and maintained with hospital booking teams in order to arrange appointments that fit in with the prison regime. This is due to a lack of formal arrangements between prisons and their local hospitals. Patients who are released following a court appearance, who had treatment planned, are not routinely given information about upcoming appointments they may have. This means they may unknowingly miss booked appointments, delaying their care and treatment. Details about patients who are being transferred to different areas are not always communicated effectively between prison healthcare teams and hospital booking teams. Often hospital booking teams are not made aware that a patient has been transferred until an appointment is missed, which means treatment is delayed. In this report HSSIB recommends that: HM Prison and Probation Service updates Prison Service Order 3050, ‘Continuity of healthcare for prisoners’, including guidance on communication of information about prison patients when transferring between prisons, and on the process when prison patients are released from court. This will reduce variation and ensure better continuity of care for patients when being transferred or on their release. HM Prison and Probation Service standardises the approach to the provision of prison officer escorts for outpatient appointments to protect the dignity of patients and reduce variability of escort slots. This will assist in reducing the likelihood of patients refusing to attend healthcare appointments, while balancing appointment availability, thus improving the continuity and equality of care. NHS England, via regional commissioning teams, works with HM Prison and Probation Service to identify barriers to using telemedicine for outpatient appointments, and then implements local solutions to promote and enhance the capability and usability of telemedicine. This aims to reduce the burden on prisons of providing escorts and the likelihood of patients not attending appointments.

Delays in the handover of patient care from ambulance crews to emergency departments (EDs) are causing harm to patients. A patient’s health may deteriorate while they are waiting to be seen by ED staff, or they may be harmed because they are not able to access timely and appropriate treatment. This national investigation sought to examine the systems that are in place to manage the flow of patients through and out of hospitals and consider the interactions between the health and social care systems (the ‘whole system’). This report brings together the findings from the investigation’s three interim reports and provides an update since they were published. You can view the interim reports on the hub: Interim report 1 (16 June 2022) Interim report 2 (3 November 2022) Interim report 3 (27 February 2023) The investigation provided further evidence of well recognised issues that contribute to patient harm. These were documented in three interim reports published on HSIB’s website. This is a summary of the findings from these reports: The movement of patients into, through and out of hospitals has a direct impact on ambulances queuing at emergency departments and creates patient safety risks and issues throughout the healthcare system (see interim report 1). Patient safety is managed differently across the healthcare system and does not consider the ‘air gap’ (see interim report 2) between health and social care. There is not a patient safety accountability framework which identifies individuals accountable and responsible for patient safety (see interim report 2). Poor staff wellbeing due to stress, moral injury, incivility and burnout (see interim report 3). Additional national investigation findings The reference investigation highlighted several challenges that reflect those found across other acute trusts in England. These national challenges include: Acute trusts not being able to accept new patients because their hospital is full despite a significant number of patients being medically fit for discharge. This means patients in hospital who no longer need to be there but are unable to be safely discharged to the right place of care. Ambulance crews caring for patients in the back of their ambulances for over 12 hours. When hospitals are unable to accept new patients, this has a direct impact on flow on other hospitals who will see these patients in addition to their own. Planned procedures may be delayed and/or cancelled due to the number of emergency procedures. Previous initiatives to improve patient flow have focussed on performance targets in EDs, such as the 4-hour standard, rather than changes to the whole system to facilitate patient flow. A key contributor to the problems with patient flow into, through and out of hospitals is not being able to discharge patients who no longer require hospital care. Seven-day a week services are expected to include daily reviews however this is not happening across all healthcare providers. The criteria to reside tool (a tool that helps clinicians determine appropriate discharge pathways) expects that patients on general wards should be reviewed twice daily to determine suitability for discharge (or need for care in hospital). This has not been consistently implemented across healthcare settings in England. Safety recommendations Department of Health and Social Care (DHSC) HSIB recommends that the Department of Health and Social Care leads an immediate strategic national response to address patient safety issues across health and social care arising from flow through and out of hospitals to the right place of care. HSIB recommends that the Department of Health and Social Care conduct an integrated review of the health and social care system to identify risks to patient safety spanning the system arising from challenges in constraints, demand, capacity and flow of patients in and out of hospital and implement any changes as necessary. In interim report 2 a safety observation was made, following the collection of further evidence this has now been escalated to a safety recommendation: HSIB recommends that the Department of Health and Social Care develops and implements a patient safety accountability framework that spans the health and social care system. This is to help address the lack of accountability relating to patient safety risks spanning health and social care. NHS England HSIB recommends that NHS England includes staff health and wellbeing as a critical component of patient safety in the NHS Patient Safety Strategy. Safety observations HSIB has made two safety observations to date as a result of this ongoing investigation. It may be beneficial for there to be a whole-system patient safety accountability and responsibility framework that spans health and social care. It may be beneficial for NHS organisations to provide time and safe spaces for staff to engage in reflective practice and talk about the emotional impact of their work, with support from people with expertise in staff wellbeing.

Delayed discharges, where a patient is medically fit to leave hospital but is not discharged, were a particular problem in England in the winter of 2022/23. In this article, Camille Oung from the Nuffield Trust highlights some possible solutions to help better prepare health and care services for discharge pressures next winter.

The eDischarge Information Record Standard was first published in 2015. Despite significant investment in programme initiatives, the widespread implementation of the standards has been slow.  In this report from the Professional Record Standard Body, authors identify the challenges that have inhibited the adoption of the standard, make recommendations for improvements and set out the anticipated benefits that this will bring. The aims of this discovery and user-design phase were: To review the current state of adoption of transfer of care messages between secondary care senders and primary care receivers of transfers of care and identify reasons for the low uptake to date. To understand GP’s needs and priorities for computer readable data that can be shared with primary care systems without loss of meaning. To make recommendations for what needs to happen to enable widespread adoption that supports the needs of GPs to deliver safer patient care. The report includes seven broad recommendations regarding e-discharge as well as recommendations regarding other transfers of care and general recommendations regarding lessons learned and their applicability to standards and interoperability generally: Recommendations regarding e-discharge Adapt General Practice systems, processes and workflow to better meet GP needs. Drive wider adoption of the standard in Secondary Care and specialist providers of care (e.g. gender identity clinics). Encourage joint system working (primary care, secondary care, patients) facilitated by ICS’s. Improve e-discharge standards and documentation to make it easier for suppliers and implementers to follow. Review and streamline assurance and conformance processes. Establish programme, leadership, governance and incentives to lead the change programme required. Recommendations for other related programmes. Recommendations for other transfers of care and for standards and interoperability generally are included in the detailed recommendations below. To be successful, the proposed approach must include the following key features: Collaborative leadership and governance including all key stakeholders (ICS, NHS E and programme teams, software suppliers, PRSB, techUK, INTEROPen) and taking a ‘whole-system’ approach. Strong involvement from Integrated Care Systems ensuring local ownership and fir for purpose solutions. Focus on clinical continuity and better outcomes for patients. Clinical and technical support to enable problem solving and rapid removal of barriers. Pilot deliverables will be assured and shared for national benefit.

Christina Ruse was admitted to the Spire Hospital on 14 December 2021 and underwent a total left hip replacement. Her condition deteriorated and observations were commenced at five minute intervals. Mrs Ruse was reviewed and on further deterioration in her condition it was decided to transfer her to the High Dependency Unit, Norfolk and Norwich University Hospital. On arrival of the ambulance Mrs Ruse was undergoing a further investigatory procedure. On this being completed Mrs Ruse was taken to the Norfolk and Norwich University Hospital, where her condition continued to deteriorate and she died on 15 December 2021. The Coroner raised the following matters of concern in this case: East of England Ambulance Trust (EEAST) were telephoned at 19.30 hours to request an ambulance to transport Mrs Ruse to the High Dependency Unit. This was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average time of 18 minutes. There were no emergency ambulances available to assign to this call due to high call demand. An ambulance did not become available until 20.54 hours and arrived on scene at 20.57 hours, by which time Mrs Ruse had deteriorated further and had been taken back into theatre. EEAST staff did wait (exceeding the period of their shift) and Mrs Ruse was taken to the High Dependency Unit at 22.42 hours. It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients. However evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur. This Prevention of Future Deaths report raises similar patient safety concerns about delayed transfers from a Spire Norwich Hospital to Norfolk and Norwich University Hospital NHS Foundation Trust to the two reports below. These three patients covered by these reports all died within a nine-month period. Prevention of Future Deaths report: Barbara Hollis (3 October 2022) Prevention of Future Deaths report: Geoffrey Hoad (13 September 2023)

Barbara Hollis underwent a total left knee replacement operation on 22 February 2022. The surgery was uneventful with no complications, however after her return to the ward Mrs Hollis became restless and confused. Following a review of her deteriorating condition the decision was made to transfer her to the High Dependency Unit at the Norfolk and Norwich University Hospital. Arrangements were made for the transfer and the ambulance service was called at 19.51 and were told that immediate clinical intervention was needed, but the agreed hospital to hospital transfer pathway was not followed. There was a two hour delay in ambulance attendance, during which time Mrs Hollis continued to deteriorate. Mrs Hollis was subsequently taken to the High Dependency Unit at the Norfolk and Norwich University Hospital where her condition continued to deteriorate and she died in the early hours of the 23 February 2022. The Coroner raised the following matters of concern in this case: East of England Ambulance Trust (EEAST) were telephoned at 19.51 hours and the caller said that immediate intervention was needed. The incorrect pathway was then followed and it is understood action has been taken in this respect. The call was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average response time of 18 minutes. At 21.17 hours a second telephone call was made to EEAST. An ambulance was on scene at 21.27 hours. There were no emergency ambulances to respond to the initial 999 call due to high demand on the service. It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients. However, evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur. This Prevention of Future Deaths report raises similar patient safety concerns about delayed transfers from a Spire Norwich Hospital to Norfolk and Norwich University Hospital NHS Foundation Trust to the two reports below. These three patients covered by these reports all died within a nine-month period. Prevention of Future Deaths report: Geoffrey Hoad (13 September 2023) Prevention of Future Deaths report: Christina Ruse (3 October 2022)

 On 3 August 2022, Geoffrey Hoad underwent a total hip replacement at The Spire Hospital. On 5 August 2022, Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise with gradually deteriorating renal function. On 6 August 2022, Mr Hoad’s transfer to Norfolk and Norwich University Hospital was agreed due to possible bowel obstruction, possible pulmonary infection and deteriorating renal function.   Ambulance service was called at 18:16 hours and again at 23.45. On 7 August 2022, the ambulance service was called again at 07.38 hours. The ambulance was on scene at 08:26 hours.         The medical cause of death was: 1a) Sub Acute Myocardial Infarction 1b)  Coronary Artery Atherosclerosis 2) Hospital Admission for Post Operative lieus. Matters of Concern Spire Norwich Hospital called the ambulance service on 6 August 2022 at 18.16 hours. The call was coded as a Category 3 call, requiring a response within 2 hours. The Spire Hospital were told the response would be 6 hours. The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call. The ambulance service was called again on 7 August 2022 at 07.38 hours and the call was now coded as a Category 2 call, requiring a response within 40 minutes and with an average time of 18 minutes. Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours. The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours. Evidence was heard as to the very high call demand overnight on 6th August 2022 and with regard to the significant pressure the healthcare system was and remains under. Evidence was also heard as to the steps being taken by EEAST in an attempt to deal with this pressure on the healthcare system. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue. Spire Norwich Hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute Trusts, usually the Norfolk and Norwich University Hospital. Spire Norwich Hospital continues to rely on EEAST to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result. At the inquest Spire Norwich Hospital placed great reliance on now being part of an lnterfacility Transfer Group led by the Norfolk and Norwich University Hospital working with the EEAST to look at a pathway in respect of inter hospital transfers. The evidence of EEAST was that this pathway was not expected to reduce delays in inter hospital transfers. This concern has been raised at previous inquest. This Prevention of Future Deaths report raises similar patient safety concerns about delayed transfers from a Spire Norwich Hospital to Norfolk and Norwich University Hospital NHS Foundation Trust to the two reports below. These three patients covered by these reports all died within a nine-month period. Prevention of Future Deaths report: Barbara Hollis (3 October 2022) Prevention of Future Deaths report: Christina Ruse (3 October 2022)

Recent polling from Healthwatch England shows that a fifth of patients referred by a GP for consultant-led care end up in a ‘referral black hole’, with more than two million patients each year having to make four or more visits to their GP before a referral is accepted. The result is that tens of thousands of patients could be on a ‘hidden’ waiting list, meaning that GPs are managing greater clinical risk and a greater number of patients whose conditions are often worsening in primary care, whilst communication between providers and access to diagnostics are often not up to scratch.  This report by the think tank Policy Exchange looks at reforms that could be made to the interface between primary and secondary care in order to improve care and prevent patient harm. It considers how improved flows of information and expertise can: better support growing demand in general practice reduce unwarranted variation in service provision enhance care coordination – particularly for those referred for elective procedures enable opportunities to boost generalist medical skills for a new generation of doctors create opportunities for hospital specialists to deliver a greater proportion of care in primary or community care settings, reducing waiting times and the use of more expensive settings for care.

Improving medication safety during transitions of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy. This study in the journal Therapeutic Advances in Drug Safety aimed to characterise the nature and contributory factors of medication-related incidents during transitions of care from secondary to primary care. The authors found several themes for future research that could support the development of interventions, including: commonly observed medication classes older adults increase patient engagements improve shared care agreements for medication monitoring post hospital discharge.