Discharge Planning

Studies show that around 20% of patients have an adverse incident within 30 days of their discharge from their respective hospitals. Three-quarters of these events could have been helped or averted with better discharge planning. Common post-discharge difficulties include hospital-acquired infections, procedural complications, and adverse drug effects. Most, if not all, of these complications can be due to discharge planning issues. For example, changes or inconsistencies in medications prior to/after patient discharge, insufficient preparation for patient and family regarding information on medications/danger signs/lifestyle changes, disconnects in clinician and patient communication, and discontinuity between inpatient and outpatient providers.

Patient and family involvement in the discharge planning process is imperative for improving patient outcomes, reducing unplanned readmissions, and increasing patient satisfaction. Hospitals are beginning to focus on transitions in care to improve hospital safety and quality. In fact, the Centers for Medicare and Medicaid Services instated new guidelines in 2012 that reduce payment to hospitals exceeding their expected readmission rates.

This document will serve to explain and expand on the Agency for Healthcare Research and Quality’s Care Transitions from Hospital to Home: IDEAL Discharge Planning tools.

What is IDEAL Discharge Planning?

Include the patient and patient’s family as full partners in the discharge planning process

Discuss with the patient and patient’s family the five areas to preventing problems at home after discharge:

1. Describe what life at home will be like post-discharge
2. Review their medications and dosages
3. Highlight warning signs and problems
4. Explain test results clearly
5. Make follow-up appointments

Educate the patient and patient’s family in plain language about the patient’s condition, the process of discharging them, and what their next steps will be throughout the hospital stay.

Assess how well medical professionals are explaining diagnoses, conditions, and the patient’s next steps using the teach back method.

Listen to and respect the patient’s and family’s goals, observations, concerns, and preferences.

This process should include at least one meeting to discuss concerns and questions with the patient, family of the patient’s choice, and particular members of your hospital’s staff.

Implementing IDEAL Discharge Planning

Clinicians

In the IDEAL Discharge Planning process, clinicians are expected to integrate the IDEAL discharge elements in their practice, make themselves available to the hospital staff who will be working with the patient and family, and take part in trainings on the IDEAL process.

Components of Discharge

The blue bullet points provide insight as to how to implement each part of the IDEAL discharge process effectively.

Include the patient and patient’s family as full partners in the discharge planning process

• The patient and family should be key players in team meetings regarding discharge. Discharge is not a one-time event, as it is a process that unfolds throughout the entirety of the hospital stay.
• Identify which family and/or friends will be providing care at home and ensure that you are including them in conversations. Do not assume the family members at the hospital will be the family members caring for the patient at home.

Discuss with the patient and patient’s family the five areas to preventing problems at home after discharge:

1. Describe what life at home will be like post-discharge

• This includes describing what the home environment should look like, how much support will be needed, what the support should look like, what the patient can and cannot eat, and activities to do or avoid.

2. Review their medications and dosages

• Use a reconciled medication list to discuss the purpose of each medication, how much to take, whether it should be taken with food, how to take it, and potential side effects.

3. Highlight warning signs and problems

• Identify warning signs or potential problems. Write down the name and contact information of someone to call if there is a problem at home. The person who would be contacted in the event of an issue should be familiar with the patient and their situation.

4. Explain test results clearly

• If test results are not available at discharge, let the patient and family know when they should have access to the results and identify who they should call if they have not gotten results by that date.

5. Make follow-up appointments

• Offer to make any follow-up appointments for the patient. Make sure that the patient and family know what follow-up(s) is/are needed.

Educate the patient and patient’s family in plain language about the patient’s condition, the process of discharging them, and what their next steps will be throughout the hospital stay.

• Receiving all the information on the day of discharge can be overwhelming. Discharge planning should be a continuous process throughout the hospital stay, not a one-time event. You can make this process more continuous using the following steps:
• Obtain patient and family goals at admission and note progress toward those goals each day
• Involve the patient and family in bedside shift report or bedside rounds
• Share a written list of medicines every morning
• Go over medicines at each administration: What it is for, how much to take, how to take it, and side effects
• Encourage the patient and family to take part in care practices to support their competence and confidence in caregiving at home

Assess how well medical professionals are explaining diagnoses, conditions, and the patient’s next steps using teach back.

• Provide information to the patient and family in small chunks and repeat key pieces of information throughout the hospital stay.
• Ask the patient and family to repeat what you said back to you in their own words to ensure that you explained things well

Listen to and respect the patient’s and family’s goals, observations, concerns, and preferences.

• Invite the patient and family to use the white board in their room to write questions or concerns
• Ask open-ended questions to elicit questions and concerns
• Use Be Prepared to Go Home Checklist and Booklet (Tools 2a and 2b) to make sure the patient and family feel prepared to go home
• Schedule at least one meeting specific to discharge planning with the patient and family caregivers

Discharge Planning Process in Pieces

Initial Nursing Assessment

• Identify the caregiver who will be at home along with potential back-ups. These individuals need to understand instructions for care at home. Do not assume that family in the hospital will be caregivers at home.
• Let the patient and patient’s family know that they can use the whiteboard in the room to write questions or concerns.
• Elicit the patient and family’s goals for when and how they leave the hospital, as appropriate. Along with input from their doctor, work with the patient and family to set realistic goals for their hospital stay.
• Inform the patient and family about steps in progress toward discharge. For common procedures, create a patient handout, white board, or poster that identifies the road map to get home. This road map can include things like “I can walk 20 steps” or “I can feed myself”

Daily

• Educate the patient and family about the patient’s condition at every opportunity, such as nurse bedside shift report, rounds, vital status check, nurse calls, and other opportunities that present themselves. Use the teach back method.

Who? All Clinical Staff

• Explain medicines to the patient and family (for example, print out a list every morning) and at any time medicine is administered. Explain what each medicine is for, describe potential side effects, and make sure the patient knows about any changes in the medicines they are taking. Use the teach back method.

Who? All Clinical Staff

• Discuss the patient, family, and clinician goals and progress toward discharge. Once goals are set at admission, revisit these goals to make sure the patient and family understand how they are progressing toward discharge.

Who? All Clinical Staff

• Involve the patient and patient’s family in care practices to improve confidence in caretaking after discharge. Examples of care practices could include changing the wound dressing, helping the patient with feeding, going to the restroom, and/or assisting with rehabilitation exercises.

Who? All Clinical Staff

Prior to Discharge Planning Meeting

When? 1-2 days prior to discharge planning meeting. For short stays, this meeting might occur at admission.

• Give the patient and family Tools 2a and 2b: Be prepared to Go Home Checklist and Booklet

Who? Hospital should identify staff person to distribute

• Schedule discharge planning meeting with the patient, family, and hospital staff

Who? Hospital should identify staff person to distribute

Discharge Planning Meeting

When? 1-2 days prior to discharge planning meeting, earlier for more extended stays in the hospital.

• Use the Tools 2a and 2b: Be Prepared to Go Home Checklist and Booklet as a starting point to discuss questions, needs, and concerns about going home
• If the patient or family did not read or fill out the checklist, review it verbally. Make sure to ask if they have questions or concerns other than those listed. You can start the dialogue by asking, “What will being back home look like for you?”
• Repeat the patient’s concerns in your own words to make sure you understand
• Use teach back to check if the patient understands the information given
• If another clinician is needed to address concerns (e.g., pharmacist, doctor or nurse), arrange for this conversation.

Who? Hospital should identify staff who need to be involved in the meeting (doctor, nurse, patient advocate, discharge planner, etc.)

• Offer to make follow-up appointments. Ask if the patient has a preferred day or time and if the patient is able to get to the appointment.

Who? Hospital should identify staff person for this

Day of Discharge

• Review a reconciled medication list with the patient and family. Go over the list of current medicines. Use teach back. Ensure that patients have an easy-to-read, printed medication list to take home.

Who? Hospital should identify staff person to review the medication list with patient and family—clinician

• Give the patient and family the patient’s follow-up appointment times and include the provider name, time, and location of appointments in writing.

Who? Staff member(w) who scheduled the appointment

• Give the patient and family the name, position, and phone number of the person to contact if there is a problem after discharge. Make sure the contact person is aware of the patient’s condition and situation

Who? Hospital should identify staff person to write contact information

Resources:

Be Prepared to Go Home Booklet

Be Prepared to Go Home Checklist

Template Medication List for Patients to Take Home

Discharge Planning Toolkit of Handouts for Patients and Staff

IDEAL Discharge Planning Checklist

Fill in, initial, and date each task as they are completed

Initial Nursing Assessment	Prior to Discharge Planning Meeting	During Discharge Planning Meeting	Day of Discharge
_______ Identified the caregiver at home and backups   ________ Told patient and family about whiteboard   _________ Elicited patient and family goals for hospital stay Informed patient and family about steps to discharge	_______ Distributed checklist and booklet to patient and family with explanation   _______ Scheduled discharge planning meeting   Scheduled for: ___/___/____ at _________ (time)	______ Discussed patient questions   ______ Discussed family questions   ______ Reviewed Discharge instructions as needed   ______ Used Teach Back ______ Offered to schedule follow-up appointments with providers.   Preferred dates/ times for: PCP- Other-	Medication _______ reconciled medication list   ________ Reviewed medication list with patient and family and used teach back   Appointments and Contact Information   _________ Scheduled follow-up appointments   1)     With _______________ on ____/___/_____ At __________(time) 2)     With _______________ on ____/___/_____ At __________(time)   ________ Arranged any home care needed   _________ Wrote down and gave appointments to the patient and family   __________ Wrote down and gave contact information for follow-up person after discharge

 

IDEAL Discharge Planning Daily Checklist

Fill in, initial, and date each task as they are completed

Day 1	Day 2	Day 3	Day 4
_______Educated patient and family about condition and used teach back method   _______ Discussed progress toward patient, family, and clinician goals   _______ Explained medications to patient and family _____ morning _____ noon _____ evening _____ bedtime _____ other   _______ Involved patient and family in care practices such as:	_______Educated patient and family about condition and used teach back method   _______ Discussed progress toward patient, family, and clinician goals   _______ Explained medications to patient and family _____ morning _____ noon _____ evening _____ bedtime _____ other   _______ Involved patient and family in care practices such as:	_______Educated patient and family about condition and used teach back method   _______ Discussed progress toward patient, family, and clinician goals   _______ Explained medications to patient and family _____ morning _____ noon _____ evening _____ bedtime _____ other   _______ Involved patient and family in care practices such as:	_______Educated patient and family about condition and used teach back method   _______ Discussed progress toward patient, family, and clinician goals   _______ Explained medications to patient and family _____ morning _____ noon _____ evening _____ bedtime _____ other   _______ Involved patient and family in care practices such as: