This document discusses strategies for alleviating patient fear after hospital discharge. It begins by providing background on regulations like the ACA that extend hospital responsibility beyond treatment to reducing readmissions. It then explores the sources of patient fear after discharge, such as fear of recurrence, pain, burdening others, and more. The document outlines how these fears can lead to consequences like improper medication use, overuse of emergency rooms, and mental health issues. Finally, it proposes three key aspects to alleviating patient fear: providing information to patients, easing the transition to post-discharge care, and providing continuous support.

1. Continuing The Journey Of
Alleviating Patient Fear:
Post-Discharge
Darien Kadens, PhD, MBA, Director of Healthcare
Research, Sodexo
Lisa Herms, MSc, Research Analyst, Sodexo

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As such, they cannot be reproduced or utilized without permission. ©2016
THE ACA READMISSIONS REDUCTIONS PROGRAM, PATIENT-
CENTERED CARE AND POST-DISCHARGE PROCEDURES
Across the globe, there has been an increasing trend toward a focus on value in the healthcare sector. Consequently,
many governments have implemented regulations that extend hospital responsibility beyond mere treatment and
reprimand for unnecessary patient readmissions. In the United States, the Hospital Readmissions Reduction Program,
established by the Affordable Care Act (ACA), penalizes hospitals for patients who are readmitted within 30 days of
discharge by a reduction in Medicare payment up to 3%. In 2015, roughly half of U.S. hospitals were penalized under the
regulation, altogether losing an estimated $420 million.1
Readmission can be linked to a problem inadequately
resolved during hospitalization (i.e., a hospital-acquired
infection, unstable heart functioning). However, it can
also be caused by a deterioration after a patient has been
discharged, such as due to inadequate – or misunderstood
– management of a patient’s condition on their own.
Interventions to reduce readmissions have therefore
historically focused both on inpatient care as well as the
transition to outpatient and home care.2
Post-discharge care is, in fact, a key pillar of patient-
centered care. Transition and Continuity – both post-
discharge themes that can be linked to readmissions – are
part of the 8 Picker principles of patient-centered care.3
In
addition, the HCAHPS questionnaire – another element of
the ACA that is linked to reimbursement – includes two major items that focus specifically on post-discharge: whether
or not patients were given information about what to do about their recovery at home, and whether or not patients
understood their care when they left the hospital.
This piece will examine the critical role of post-discharge care and how it is shaped by the existence and alleviation of
patient fear. Steps and best practices to alleviate this fear are also described in detail.
POST-DISCHARGE AS THE NEXT STEP IN THE JOURNEY
Care does not stop when a patient leaves the hospital. For the patient, the journey to recovery is not completed once the
patient is wheeled out of the facility, but only just beginning. However, the general sentiment among the patient population
is often that following their discharge, they are on their own, thrown back into everyday life as if nothing has happened.
With the immediate threat of illness or fatality resolved, the reality of everyday life post-hospitalization is daunting,
augmented by potential stigmatization, isolation, and a large amount of catch-up work required for things left undone
while away. All of these contribute to a feeling of being overwhelmed, thereby leading to anxiety and, more fundamentally,
fear among post-discharge patients. This fear, if left unacknowledged, can have severe implications for readmissions and
patient outcomes, thereby impacting providers’ financial sustainability as well as patient and caregiver quality of life.
Therefore, it is vital that healthcare providers begin to focus on the post-discharge period and the transition to out-of-
hospital care as a key milestone – rather than the finish line – in a patient’s recovery path. To examine this from the most
fundamental perspective, providers ought to consider the underlying feature that has already been the guiding principle
of patient in-hospital care: the understanding and alleviation of fear.
Post-discharge care is
a key pillar of patient-
centered care.

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As such, they cannot be reproduced or utilized without permission. ©2016
SOURCES OF PATIENT FEAR POST-DISCHARGE
The transition from the hospital back to normal life
is defined by attempts to regain control after the
depersonalization and loss of control experienced by a
patient during the hospital stay.4
A hospital is one of the
few places where an individual essentially forfeits control
over every task (s)he normally performs.5,6,7
Patients
are monitored 24 hours a day, and their daily routine is
prescribed to them. Even with the best and most patient-
centered inpatient care, a patient still loses autonomy
and the ability to make individual decisions.
In the search to regain this autonomy after discharge,
there are many psychosocial sources of fear a patient
encounters. Based on academic studies, first-hand
interviews, and reviews of patient support groups and
social media, one can identify several key sources of
fears (Figure 1). Many are universal, while some are more
prevalent in certain subgroups of patients.
Fear of Being
a Burden
Fear of Needing
(and Being
Unable to
Adapt)
Fear of Remission,
Recurrence &
Complications
Fear of Doing
Something
Wrong
Fear of Pain
Fear of
Stigmatization
Fear of Falling
For patients, the
transition from the
hospital back to
normal life is defined
by attempts to
regain control.
Figure 1. Common Sources of Patient Fear Post-Discharge

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As such, they cannot be reproduced or utilized without permission. ©2016
One of the most fundamental fears repeatedly
mentioned throughout is the fear of remission,
recurrence and complications.4,8,9,10
This fear is so
severe and prevalent that patients and those who care
for them have coined a name for this phenomenon: living
under the sword of Damocles.11
It is especially prominent
for cancer survivors. In fact, recent systematic reviews
of academic literature suggest that around 50% of all
cancer patients experience moderate to severe fear of
remission.12
Combined with a fear of recurrence, patients are afraid
that failure on their part to complete a required task
– from caring for their wounds to following any other
instructions – will have significant consequences. The
fear of doing something wrong can stem from confusion
about post-discharge instructions and insecurity about
what is and is not “normal” for certain ailments.
Depending on the illness or procedure, patients may be
afraid of facing significant pain after discharge. This is
augmented by the perception that once patients leave
the hospital vicinity, they no longer have ready access to
proper pain mediation dosages, leaving their pain either
undermanaged or overly managed with excessive self-
medication.13,14,15,16
Some patient groups experience a fear of stigmatization
when they return to their community. In the words
of one cancer survivor, “Everyone is living their life…
and then there’s you, who had cancer.” Sometimes
hospitalization leaves behind visible signs – scars, hair
loss, bandages or walking aids – all of which make it
obvious to the community that a patient has received
treatment. Despite the increase in public awareness
about many health conditions, many people still see
illness as something to be ashamed of – something for
which others will blame and stigmatize them. Even if
stigmatization is only felt, as opposed to enacted, a
patient may experience this fear.17,18,19
For physically debilitating illnesses or incidents, patients
– especially the elderly – often cope with a fear of falling
down.20,21,22
For many, a fall would be symbolic of losing
autonomy again, and would potentially lead to a relapse
or readmission to the hospital.
Lastly, a fundamental fear of discharged patients is
the fear of needing to adapt to a new lifestyle and an
inability to do so,9,23
coupled with the fear of being a
burden to those around them.24
Rarely can a patient
“jump right back into” the life they lived before. At the
very least, temporary adjustments will be required;
from physical limitations as wounds heal, or due to new
routines, diet restrictions, certain medications, or wound
treatment procedures.
In this struggle for adaptation, patients may view
themselves as burdens. Patients may fear being a burden
in the long-term, especially when they are discharged
and diagnosed with a chronic illness that will require
further and continuous treatments. Even patients
with short-term physical limitations may fear being
a burden. Interestingly, this particular fear seems to
be ungrounded – or at least not as severe as patients
imagine. Studies show that patient estimates of the
burden experienced by their caregiver are higher than the
caregiver’s own perception of their burden.25
IMPLICATIONS OF PATIENT
FEAR POST-DISCHARGE
Patients experience different fears with varying severity,
depending on their condition, the experience they had
during the hospital, and their existing support network
outside of the hospital. These factors also influence a
patient’s fear-coping mechanisms after discharge, and
the resulting consequences.
Patient Fear-Coping Mechanisms
Fear is universal, but the way we manage it is not. Just
as we have previously identified patient fear-coping
mechanisms during a hospital stay,26
so can we expand
this notion to how patients will react to the fear they
face once they leave the hospital. A patient does not stop
being a patient just because they leave the confines of
the hospital bed.
Sodexo’s proprietary behavioral segmentation tool,
PersonixTM
, systematically applies factor analysis to
segment patients into one of six fear-coping mechanisms
(Figure 2). While originally designed to explain the
behavior observed inside the hospital, there is reason
to believe that these coping mechanisms are also
transferred to the recovery phase, including when
individuals return from the hospital.

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As such, they cannot be reproduced or utilized without permission. ©2016
Self-centrics individualize their treatment
and recovery path by focusing on what they
want and how they want to approach the
transition. They look to manage everything
individually and to their own liking.
Minglers seek support from anyone who
will listen – whether hospital staff, friends
and family, community members, or fellow
patients or survivors.
Worriers rely on continuous explanations,
coaxing, and reassurances about their state
and progress.
Attention-seekers continuously have
questions about their care and will not be
shy about asking around, in an attempt to
stand out as a patient or survivor.
Acceptors controlled their fear in the
hospital by following well-defined treatment
plans. Accordingly, in the transition phase
and post-discharge, they continue to look
for guidelines, schedules and
instructions for the proper steps
forward.
Loners seek to remain isolated in the
hospital, and they will continue to shy
away from human contact post-discharge
– whether it is with follow-up clinical staff,
friends and family, or patient/
community support offers.
At any given point in time, patients may fall into one or more of these six clusters. The coping mechanisms exhibited
by each individual have implications for the consequences of fear post-discharge; a better understanding of this can
ultimately serve as a starting point for initiatives to alleviate fear.
Figure 2. PersonixTM
Patient Fear-Coping Mechanisms

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As such, they cannot be reproduced or utilized without permission. ©2016
CONSEQUENCES OF PATIENT
FEAR POST-DISCHARGE
Fear is clearly an undesirable phenomenon – for
any individual, but especially for patients who have
undergone a period of intense physical and emotional
stress. Fear can lead to adverse physical reactions
that can hinder or inhibit successful recovery. In
addition, when coupled with confusion and incomplete
medication, fear can lead to medication misuse and
missed warning signs.
Improper Use of Pain Medication
Research has found that in cases when significant pain
and the extensive use of pain medication were key
factors during a patient’s stay, a patient may continue
to take opioids post-discharge. Yet, this may not be
advisable. In very extreme cases, fear of pain and
confusion about medical consequences can result in
some form of opioid addiction.13,27
Alternatively, a fear
of addiction to painkillers may prevent individuals from
taking medication when, in fact, they should.28
Overutilization of Emergency Room
Fear can also lead patients to over-interpret certain signs
and signals, resulting in unnecessary readmissions and
emergency room visits. Many patients are concerned
that their primary care physician or caregiver don’t have
the means to treat them properly, only to find out after
visiting the ER and being readmitted that most of their
concerns could have easily been managed outside of the
hospital setting. Other times, patients are concerned
about long wait times or appointments that are spread
out over time, worried that they require or would benefit
from immediate treatment. While some patients do
require immediate medical assistance, blind fear post-
discharge should not be the primary driver behind future
emergency room visits.
Reluctance to Attend Follow-up and Post-
discharge Care
Another angle to consider in discussing the consequences
of patient fear after hospitalization comes from
behavioral economics. Studies have identified what is
known as the “peak-end rule.” According to the peak-end
rule, people judge an experience based largely on how
they felt at its “peak” – the most intense point in time
– and at its end, rather than based on the total sum or
perceived average of the entire experience.29,30
In terms
of medical treatment, this means that in looking back at
the care they received in the hospital, patients will focus
on the most intense moments – likely of pain and fear –
as well as the last impression they had of the care they
received – likely the discharge procedure. If either one of
these is intensely painful or induces fear, the patient may
remember the entire hospital episode as being intensely
painful or fear-inducing.
In terms of follow-up and post-discharge care, this means
that patients may be more hesitant to return to the
hospital. They may ignore certain warning signs, miss
vital follow-up visits with their physicians, and abstain
from future prevention procedures. This can jeopardize a
speedy and safe recovery outside of the hospital. Empirical
examples have focused on preventive procedures such as
mammograms, colonoscopies, or dentist visits.31,32,33,34
But other studies have examined hospital visits, showing
that memory of pain and recall of the hospital episode –
whether they are accurate or not – are valid predictors of
patient stress and anxiety post-discharge.35
Patient fear can
lead to medication
misuse and missed
warning signs.

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As such, they cannot be reproduced or utilized without permission. ©2016
Mental Peace of Mind and Health Issues
Lastly, the presence of fear post-discharge can have severe consequences for a patient’s mental health. The feeling
of being helpless and alone after being released from a hospital where a patient receives 24-hour assistance and
supervision can lead to depression.
There are many facets to patient fear post-discharge, and the consequences and severity of fear clearly vary from
individual to individual. However, the common thread beneath these diverse implications is that all of them may lead
to some form of hospital readmission – likely in an emergency situation. Given the limited resources of the healthcare
system, healthcare professionals must focus on and combat fear as one of the most fundamental drivers of hospital
visits post-discharge (aside from medical necessities).
ALLEVIATING PATIENT FEAR AFTER HOSPITALIZATION
Regardless of the specific fear-coping mechanism an
individual exemplifies, the key solution in alleviating
patient fear after release from a hospital revolves around
providing information and support. The underlying reason
fear is experienced post-discharge is an attempt by the
patient to regain control and sense of self, which is usually
met with some hurdles. As a result, initiatives that seek
to alleviate fear should focus on guiding and empowering
patients.
With this as a guiding framework, there are three key
interconnected aspects of post-discharge fear alleviation:
providing information, easing the transition, and
continuously supporting (Figure 3).
Guiding and
empowering patients
is key to alleviating
their fear.
Figure 3. Steps to Alleviate Patient Fear Post-Discharge
Figure 3.
PROVIDE INFORMATION EASE THE TRANSITION CONTINUOUSLY SUPPORT
Discharge Procedure
Buffer Lounge
Medical Discharge Summaries
Patient Discharge Instructions
Technology to Support
Medical Staff Contact Information
Comfort/Supply Pack
Support from Staff
Support from Fellow Patients
Support from Family & Caregivers
Support from the CommunityHome Transport
Concierge Service

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As such, they cannot be reproduced or utilized without permission. ©2016
Step 1: Provide Information
A primary aspect of easing patient fear post-discharge that is most frequently found in the research is the need to
provide information.36
Every hospital stay is chronicled in a final discharge document that is issued to the patient, either proactively or upon
request. Obviously, there are many benefits to making this document readily available to patients. In theory, this
transparency will help the patient to make healthier and more informed decisions about their activities and care. There
is the ethical argument that a patient ought to have access to information about them. And then there is the practical
benefit that this document can be utilized by a patient’s primary care physician and caregivers as a resource.
However, the idea of relying on this
document as a patient’s primary
source of information has met with
some resistance. Physicians worry that
patients would be unable to comprehend
their notes, leading to more questions
than answers. A resulting “dumbed-
down” document that eliminates
medical jargon would displace the
primary role of the document as an
instruction sheet for the primary care
physician and future medical visits.
Furthermore, these documents may
not be comprehensive enough to give
patients all the information they need.
A review of studies on this subject
found major flaws in the discharge
summaries. Often, these documents
lacked key information, including a
patient’s main diagnosis or a list of
medications to take post-discharge.
Summaries were found to be either too
lengthy and often redundant, or overly brief and unspecific. The issue of promptness adds to the problem. Oftentimes,
discharge summaries did not reach the outpatient doctors or patients in time – or at all – for the follow-up visit and
immediate support post-discharge.37
While the timeliness of the documents may be improved through incentives from
insurers, a push for speed and quantity may be detrimental to the quality of the writing.
The research clearly indicates the need to better target patient needs, and provide them with more detailed information
about everything from medications to wound dressings and side effects. Any document targeting the patient, however,
must be easily understandable – void of medical jargon and extremely user-friendly. Ideally, the document should utilize
images and pictures, to make it comprehensible to non-native speakers or those with poor literacy. One approach has
been to utilize technology as a means to create a dialogue throughout the patient’s hospital experience and during their
recovery at home.38,39
Lastly, it is vitally important that patients feel that they are still connected to their healthcare provider, even when
they are no longer within the walls of the hospital. As part of the communication- and information-sharing initiative,
providing them with instructions on how to contact their physician and medical personnel can provide a sense of
comfort and connection.

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As such, they cannot be reproduced or utilized without permission. ©2016
Step 2: Ease the Transition
Most research focuses on the role of information in alleviating patient anxiety. However, providing information may not
be enough. The healthcare profession must consider the post-discharge period as a process and journey requiring more
comprehensive support.
The initial post-discharge period for a patient is a time of transition and adaptation. This uncertainty is met with fear
and all the potential negative consequences described above. A key role for a healthcare organization is therefore to help
to ease the transition during and immediately after the discharge procedure. This support can help make the shift from
everything being taken care of to being entirely on their own less drastic for patients.
Easing the transition can encompass many elements:
§§ A key factor, of course, is the actual discharge procedure. Giving patients the immediate opportunity to schedule their
next appointments and follow-up visits has shown to significantly improve adherence and ease anxiety for certain
subgroups.40
§§ Patients may benefit from some form of buffer zone or discharge lounge between their hospital room and the
hospital door, which allows them to gather their strength and mentally prepare themselves for the next stage.
§§ Patients can be equipped with a comfort or supply pack that goes beyond the medical discharge papers – cosmetic
or sanitary equipment, wound dressings/first aid materials, snacks or the local news to bring them up-to-speed
with their community happenings.
§§ A home transport service can provide a more gradual departure from the hospital setting. Patients are brought
home in comfort and can even have professional assistance onboard to help ease any tensions and answer
questions.
§§ In the first few days back home after a hospital stay, patients may benefit from concierge-style services. These could
range from arranging lawn mowing, house cleaning, or home grocery deliveries, to equipping a patient with a meal
service to help them get through the first few days at home.
While it may not be feasible to provide all of the services and amenities listed above, any attempt to comfort patients or
alleviate their stress will be impactful as they transition back to their home environment.

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Step 3: Provide Continuous Follow-up and
Support
Throughout this transition phase and beyond, healthcare
professionals must be sure to provide continuous
support and follow-up to patients, even beyond the
immediate recovery period.
Support from staff: This support can include follow-up
calls with healthcare staff to ensure that, after leaving
the hospital, patients are still comfortable with their
medications and tasks they need to care for themselves.
This “check on me” service with a phone call and a
dedicated contact person for continuity of support can
be targeted at medical inquiries and reassurances, or it
can simply be a source of connection for casual check-
ins and reassurance. After implementing a discharge
program that included a follow-up phone call post-
discharge, one hospital saw readmission rates drop by
40% in less than six months. This follow-up support
ensured that patients understood and could meet their
post-hospital orders for optimal recovery.41
Support from fellow patients: The importance of
patient support groups cannot be understated, whether
organized privately, by a hospital, or in the community.
Patient survivors often welcome the opportunity to
connect with others who have gone through the same
experience; these relationships are distinct from the
top-down interactions they have with medical personnel.
Joining a virtual forum or an in-person patient group
can serve as a source of information and connection.23
Studies suggest that standardized information for
patients is inadequate – receiving peer support from lay
people with similar experiences may be more valuable.8
Support from family and caregivers: Family members
and informal caregivers play a vital role in combating
patient fear. Relatives and informal caregivers are often
the link between medical personnel and the patients
themselves – the key to making patients feel safe.42
Healthcare professionals can therefore support patients
by supporting their caregivers as well. Providing better
support, coaching, and training to caregivers can
reassure patients that they are in good hands and not an
overwhelming burden to their loved ones.
Support from the community: Community support plays
an important role in the discharge process, especially for
patients who require ongoing non-acute care. There is a
broad array of community service providers and agencies
to make sure the patient has the tools and support they
need to succeed. However, these organizations must
work collaboratively with hospitals – across the hospital–
community interface – to effectively discharge patients
and word toward alleviating post-discharge fear.
CONCLUSION
Fear is a fundamental reaction in times of uncertainty
and is at the heart of an episode of illness. A patient’s
entire hospital stay is shaped by the perception of fear,
and this fear does not dissipate once he or she returns
home. While the sources of post-discharge fear and
the severity of consequences differ from patient to
patient, the detrimental effects of this fear on successful
recovery remain an ever-present threat.
Providing patients with appropriate information is
necessary, but alone is not sufficient enough to fully
alleviate fear. Healthcare providers must also help
ease a patient’s transition back to everyday life and
provide continuous access to support from informed
stakeholders – whether medical staff, patient survivor
groups, or informal caregivers.
If these steps for addressing patient fear can be
formalized and successfully implemented, readmission
rates will drop, HCAHPS scores will rise, and patients will
recover more quickly. This can only occur, however, if
providers and healthcare professionals remember that a
patient does not stop being a patient – and fear does not
stop existing – simply because of hospital discharge.

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The authors also utilized Web scans of patient support forums, which will not be disclosed here to preserve anonymity. The
authors also conducted primary interviews with discharged patients, whose names will also not be disclosed.