Discharge planning is a critical element of the admission process for patients to a hospital or healthcare facility. It is a proactive part of treatment that ensures a smooth transition for the patient back to their home or to another healthcare setting to minimize potential re-admissions and promote overall well-being.
The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoP) §482.43(c) require hospitals to identify patients at risk of adverse health events post-discharge, develop comprehensive discharge plans, and actively involve patients and their caregivers in the process. These plans must address the patient's goals and treatment preferences. It is imperative that healthcare organizations have a robust and proactive approach to discharge planning to ensure optimal and efficient healthcare is provided to support the patient in achieving their healthcare goals.
Leaders should monitor their discharge planning process to confirm it meets regulatory requirements and identify opportunities for improvement.
Areas for review of your discharge planning process should include the methods of:
- Initial Assessment
- Plan Development
- Ongoing Communication/Education
- Coordination of Services
- Post-Discharge Follow-up/Evaluation
Initial Assessment
When the organization first evaluates the patient’s status. This includes a needs identification where staff assess the patient's medical, social, and functional needs to determine the resources and support they will require after discharge. The patient’s functional status is assessed to evaluate the patient's ability to perform daily activities and identify any limitations that may require additional assistance. This can extend to assessing the home environment to determine if it is safe and suitable for their needs upon discharge. Further, the patient’s support systems, including an evaluation of the patient's social network, including family, friends, and caregivers who may be available and willing to assist the patient after discharge. The information gathered during the initial assessment creates a gap analysis between needs and resources that feed into the patient’s discharge plan. Performance reviews should include the completeness of documentation with assessments.
Discharge plan development
This involves creating an individualized care plan that addresses the patient's needs, goals, and preferences. This would include medication reconciliation, where the healthcare team would thoroughly review the patient's medications, ensuring accuracy and avoiding potential drug interactions. As the patient’s hospital stay progresses and a discharge date is confirmed, the plan must address any follow-up appointments with healthcare providers that may include arranging for any required tests or procedures. If the patient is to be discharged home, the plan may need to include caregiver training for family or friends to ensure they can provide adequate care. Discharge plans may need updating depending on the progress of the patient toward meeting their discharge goals or in the event of changes to their health status or changes in the availability of support. The organization should monitor for completion of the Discharge Plan within organizational timeframes and updates to the plan when changes occur.
Ongoing communication and education
As the discharge plan continues, ongoing communication and education must be conducted to support the smooth transition of the patient to either home or a facility for assisted/skilled care or rehabilitation. This would include maintaining interprofessional communication between healthcare professionals, patients, and caregivers to ensure a coordinated approach to care. In the event of changes to the discharge plan, all healthcare team members, the patient, and support members must be kept apprised of updates and progress. Additionally, communication with the patient and their family about the discharge plan, including medications, home care instructions, and potential problems to watch for at home. If the patient won’t be discharged home, it’s imperative that communication with the facility where the patient will be sent is supported to ensure an unencumbered transition. Organizations should review their processes for communication with the healthcare team (internal and external) and the patient/family members. This may include documentation of attendance of family members and staff in healthcare team meetings.
Coordination of services
Integrated throughout the discharge planning process is the coordination of services, where the organization ensures that the various disciplines involved in the patient’s discharge process are synchronized to the patient’s discharge goals. It’s also essential that these entities can adjust to any changes in the patient’s health status or identification of new needs. Coordination of referrals is critical for necessary community services, such as home health, therapy, and social support, which are needed to support the transition. The organization may need to arrange transportation to and from appointments and ensure access to necessary equipment and supplies. Coordination of services will include verifying insurance coverage for post-discharge care and obtaining appropriate authorizations. Organizations must review their coordination efforts for discharge planning to identify opportunities that can hinder the establishment of support for the patient. Monitoring for delays with coordinating services can assist in identifying process issues. The organization should establish expectations of initiating and responding to referrals as a performance threshold.
Post-Discharge Follow-up/Evaluation
After patient discharge, a review and evaluation of the discharge process must be conducted to identify opportunities for improvement. Organizations should evaluate patient outcomes specifically to determine if patient discharge goals were met. There should be a means to solicit feedback from patients and caregivers to identify elements of the discharge planning process that worked well and which need improvement. Findings and observations obtained from post-discharge evaluations should be aggregated and evaluated to determine if there are trends for improvement. Analysis should be shared and reported to leadership so successes can be celebrated and opportunities addressed.
Timely and comprehensive discharge planning helps with patient and/or family satisfaction and can assist with minimizing the number of re-admissions when the plan is the most appropriate for the patient. The organization must ensure its discharge planning process is comprehensive enough to address various post-hospital care challenges while adjusting to changing needs.
For questions or to learn more contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
