I still remember the feeling of relief standing by my uncle’s bedside. The monitors were humming with steady rhythms; the surgical team was congratulating themselves on a textbook procedure. By all clinical metrics, he was a success story. The intervention worked. The pathology was addressed. He was “stable.”

We celebrated his discharge as a victory lap. We trusted that the packet of papers in his hand (filled with appointments, medication schedules, and wound care protocols) was a sufficient map for his journey home.

We were wrong.

Within weeks, my uncle was back in the hospital. The “successful” surgery was undone not by a slip of the scalpel, but by a failure of translation. He had gone home to a world that didn’t speak the language of the hospital. He didn’t understand the nuances of his medication. He couldn’t navigate the complexity of his own recovery.

We treated his condition perfectly, but we failed his life.

This tragedy birthed a concept I now call the “patient carryover crisis.” It is the dangerous, silent void that exists between the clinical discharge and the patient’s living room. It is the moment where the high-tech safety net of the hospital vanishes, leaving vulnerable people to walk a tightrope of medical jargon and complex care routines they are ill-equipped to handle.

The distinction between the “patient” and the “person”

In modern health care, we have become experts at treating the “patient.” The patient is a collection of symptoms, a billing code, a set of vitals, and a bed number. The patient is manageable. We have protocols for the patient. We have EMR checkboxes that confirm the patient received their discharge papers.

But we frequently fail to see the “person.” The person has anxiety that clouds their memory. The person may have a fifth-grade reading level or face a language barrier that turns our “plain English” instructions into gibberish. The person goes home to a house with stairs they can’t climb, a refrigerator that lacks healthy food, or a support system that is just as confused as they are.

When we hand a packet of instructions to the “patient” and ask, “Do you understand?” they will almost always nod yes. They nod out of fear, out of deference to the white coat, or out of a desperate desire to just go home.

Accepting that nod as truth is where the system breaks.

Moving from documentation to verification

The Department of Justice and CMS are increasingly cracking down on “substandard care,” equating high readmission rates with a failure to provide essential services. But for those of us on the front lines, the issue isn’t legal; it’s moral.

To solve the patient carryover crisis, we must fundamentally shift our discharge philosophy from compliance to competency.

It is not enough to document that we told the patient what to do. We must audit whether they learned it.

This requires the rigorous application of the teach-back method and Carryover Skills Training (CST). We have to stop asking closed-ended questions like “Do you have any questions?” and start issuing gentle challenges: “Show me how you will draw up this insulin when you get home,” or “In your own words, tell me what sign would make you call 911.”

We must engineer workflows that account for cultural nuance. If a dietary restriction conflicts with a patient’s cultural staples, and we don’t discuss an alternative, that patient will choose culture over compliance every time. That isn’t non-compliance; that is our failure to engage the person.

The cost of the gap

Hospitals lose millions annually in HRRP (Hospital Readmissions Reduction Program) penalties because of this gap. But the financial loss pales in comparison to the erosion of human trust.

My uncle’s passing was a wake-up call that changed the trajectory of my career. It taught me that the most dangerous time in health care isn’t always on the operating table; sometimes, it’s the drive home.

We have the technology to treat complex diseases. We have the skills to perform miraculous surgeries. Now, we must develop the discipline to ensure that care carries over.

Let us stop celebrating the discharge signature and start celebrating the verified carryover. Only then do we honor the person, and not just the patient.

Rafiat Banwo is a health care operational and transformational leader, visioneer, and founder of the CATALYST Network, an initiative dedicated to solving her coined term, the “Patient Carryover Crisis,” and reducing avoidable patient readmissions that create penalties and risks for SNFs and hospitals worldwide through health literacy and workflow engineering. Her publication, The Patient Carryover Crisis, highlights this work. She can be reached through her LinkedIn profile and the CATALYST Network Consults website.