Discharge planning

Discharge planning is the preparation that takes place before a patient leaves a hospital, nursing home, or any other health care setting, and ensures that the patient is prepared for life outside the facility. A thorough and comprehensive plan is often necessary to ensure that the patient has the information and resources they need once they leave the facility, whether they are going home or to another facility, such as a rehabilitation center or assisted living. Such plans require the in-depth understanding of the patient, health care staff, and patient representatives who make up the planning team. Checklists are typically given to the planning team prior to the patient’s departure to ensure all essential action items are followed through. Typical action items include patient health programs, recovery and support activities, and caregiver responsibilities. It is important for patients and/or their representatives to be aware of the patient’s health conditions, persons to contact when problems occur, and information about drugs that are prescribed and suggested, including each drug’s name, mechanism, dosage, usage directions, and side effects. A list of resources, such as community services and health care agencies, may also be provided to aid in making long-term care decisions once the patient is discharged.

Background

Cooperation and understanding between the patient, health care providers, and caregivers is essential in securing a healthy and smooth discharge process. Ideally, discharge planning describes the patient’s residential settings, follows a comprehensive medication review, highlights symptoms that are cause for concern and should prompt the patient to contact health care providers, accompanies test results with detailed explanations, and schedules follow-up appointments and visitations. Educating patients and caregivers on the patient’s condition, discharge process, and steps after discharge is essential in securing the continuous implementation of discharge planning. Similarly, accurate physician assessments and nursing assessments are crucial in defining the proper diagnosis, condition, and action steps for recovery. Meetings prior to patient admission and after discharge help minimize complications that can disrupt patient recovery. Such complications can arise due to changes in medications, inadequate preparation to recognize danger signs and make lifestyle changes, disconnected communication between clinicians and patients, or miscommunications between inpatient and outpatient health care providers.

Overview

Different types of health care providers may have different discharge planning processes, although there are similarities between these processes as well. Acute-care hospitals, inpatient rehabilitation facilities, and long-term care hospitals all have similar discharge planning processes, wherein the discharge destination of the patient is first evaluated, followed by the transition pathway toward this destination, and the identification of the patient’s pre- and post-discharge requirements. The patient’s attending physician must first request a discharge plan once it is appropriate given the patient’s state of health. An interdisciplinary team of caregivers, health care professionals, pharmacists, and social workers will then determine a suitable discharge plan that follows federal and state health and safety standards. High risk criteria are identified and available local services and facilities—such as nursing facilities (NFs) or skilled nursing facilities (SNFs), long-term acute care, rehabilitation centers, home health care, and hospice—are listed to allow coordination and evaluation with the discharge planning team.

While discharge planning is not required for patients who undergo outpatient care or who are not admitted for inpatient services, it may be provided for those undergoing select outpatient procedures, such as those receiving emergency care in an acute-care hospital or same-day surgery patients. Patients, patient representatives, and attending physicians all have the right to request for a discharge planning evaluation, especially for patients who have been identified to have potential risks of adverse health consequences outside the health care setting. The discharge planning evaluation should ideally be completed soon after admission and updated throughout the duration of the patient’s admittance, as it will be included in the patient’s clinical record. By doing so, health requirements and the summary of treatments, symptoms, pain management, and seclusion/restraint orders can be evaluated over time to determine if the patient’s health has improved, remained constant, or worsened, and the discharge plan can be updated accordingly. Clinical records are available for release to the respective authoritative agencies and individuals, with the consent of the patient and patient representatives. Home health agencies and a SNF will be provided to the patient if necessary.

Hospices have similar discharge planning processes to those of other facilities, although planning is tailored toward the palliative care and management needs of patients with terminal illnesses and related conditions. The discharge planning process for hospices must account for positive changes in the patient’s health condition (stabilization) if the patient no longer fits the criteria for being placed on the terminal illness certification or recertification list, and must include education and counseling for the patient and the family. A written discharge order must be obtained from the hospice medical director and consultation with the attending physician is necessary to complete the hospice discharge summary, which includes the treatments, symptoms, pain management, seclusion/restraint orders, current plan of care, orders, and all other documentation.

Inpatient psychiatric facility discharge plans address alternative psychosocial and behavioral assessments, summarize the treatment goals, and indicate which goals have been achieved. Planning must consider means for intervention, medications, services, and all special needs for the particular patient outside the health care setting. Patients from long-term care facilities, on the other hand, are discharged to private residences or other NFs or SNFs. A post-discharge plan of care must consider the patient’s, family’s, and/or caregiver’s care preferences, accessible services, and additional coordination with other caregivers, if necessary.

Bibliography

Agency for Healthcare Research and Quality. "IDEAL Discharge Planning Overview, Process, and Checklist." Guide to Patient and Family Engagement. Rockville: AHRQ/HHS, n.d. Digital file.

Centers for Medicare & Medicaid Services. Your Discharge Planning Checklist. Baltimore: Medicare, June 2015. Digital file.

"CMS Proposes Prioritizing Patient Preferences, Linking Patients to Follow-Up Care in Discharge Planning Process." ED Management 28.3 (2016): 30–32. Print.

Medicare Learning Network. Discharge Planning. Washington, DC: Dept. of Health and Human Services: Oct. 2014. Digital file. CINAHL Complete. Web. 29 Aug. 2016.

"New Discharge Planning Rules Focus on Preferences, Transitions." Hospital Case Management 24.2 (2016): 17–20. CINAHL Complete. Web. 29 Aug. 2016.