Patient Care Coordinators (PCC) play a pivotal nursing role by ensuring patients’ needs are met after they leave the hospital. As part of the American College of Surgeons Geriatric Surgery Verification Program, all patients must receive vulnerability screening at discharge to evaluate for changes in frailty while hospitalized.  This process helps identify potential risks and implement appropriate interventions to proactively reduce complications and readmissions. Our aim was to ensure that patients enrolled in the Senior Surgical Care Program (SSCP) would have a multidisciplinary note used to address the vulnerabilities documented in their electronic medical record (EMR) at the time of discharge by the PCCs.  The vulnerability assessment focuses on mobility, nutrition, cognition, delirium, and functional status.

After implementation of the new smartphrase and documentation tools, the PCC team demonstrated consistent improvement in discharge assessment completion. Performance reached the team’s targeted benchmark during most months of the evaluation period, reflecting increased reliability of the process and reinforcing safe, effective transitions of care.

Between July 2024 and January 2025, 142 patients were discharged from our facility after participating in the SSCP. Prior to the adoption of the smartphrase, discharge assessment completion rates stood at 60%. With the implementation of the new documentation tools, the PCC team set an ambitious target of at least 80% completion. The target of 80% was met for five of the six months since the project was implemented, demonstrating noteworthy progress in our discharge assessment practices and patient care continuity.

Assessing geriatric vulnerabilities in older adults at discharge is crucial for ensuring the safety and well-being of our older adult patients. Next steps include evaluating the data from the discharge summaries to determine the impact on morbidity and readmission rates. This success reflects the dedication of our entire PCC team, whose efforts brought this vision to life. Special thanks to Quality Nurse Consultant Lynn Utecht, MSN, RN, CNL and PCC Manager Sylvia Su, MSN, RN, for their leadership in moving this initiative forward.