When does discharge planning ideally begin?

The Importance of Caregivers

The discharge conversation starts soon after you’re admitted. Discharge planners work closely with your providers to understand the care goals and potential barriers to discharge. They work to eliminate those barriers to smoothly transition you back to your home or a post-acute care facility. 

That’s when the conversation starts happening with your caregiver as well. They’re the expert on you. Discharge planners need to understand your living situation and support system. The more present your caregiver is at the hospital, the better sense discharge planners have of your baseline and whether your recovery needs are too extensive for home. 

Caregivers, be honest about what you’re able to handle. Maybe you have an employment or financial situation that prevents you from giving your loved one the care that they need. Help paint a clear picture of what’s happening at home so everyone can arrive at a discharge plan that makes sense.

The nursing staff is there to educate you on dressing wounds, emptying drains, administering medicine, etc. But you also need to ask yourself if you’re comfortable being that care person and if you understand the extent of what you need to do and how to do it. 

There’s no shame in admitting that you can’t care for your loved one at home. Communicate that as early as possible so discharge planners can begin the process of looking into a post-acute care facility or helping you find in-home assistance. It’s easier to cancel plans if you get to a place where you’re comfortable caring for your loved one than to find out at discharge that going home is not a realistic option for them.

Get SMART About Discharge

Much like a hospital stay, discharge can be overwhelming. As a patient or caregiver, you’re processing a lot at once. A simple acronym – SMART – can help you understand what’s expected of you and what kind of questions you need to ask. At discharge, you and the care team should review: 

S – Signs and symptoms that need to be reported to the patient’s provider
M – Medications that need to be taken and instructions for each
A – Appointments that need to be arranged 
R – Recommendations and restrictions for the patient's care 
T – Talk about any questions or concerns you have before discharge

If you don’t understand something, ask! There are no dumb questions. Something that may seem normal to a health care provider can be new to you. Continue to ask questions once you’re home. Ideally, discharge should occur early in the day, which gives patients and caregivers time to process that transition out of the hospital and ask follow-up questions while their provider’s office is still open.

Discharge in the COVID-19 Era

The COVID-19 pandemic has touched almost every process at hospitals, and discharge planning is no different. Depending on a facility’s visitor policy, caregivers may not be allowed to visit, or their hours may be limited. Care teams and discharge planners have had to rely more on technology to determine if a patient is close to their baseline. Communication and education with caregivers has become more intentional, requiring discharge planners to think even further ahead to ensure a caregiver is present at discharge to receive education. 

COVID-positive patients present a different challenge because of stricter visitor policies. Recovered patients may be returning to a household where others were infected but never developed serious symptoms. It takes extra communication and education to help those family members understand the care their loved one requires. And many discharged patients who are still COVID-positive face logistical challenges. Can they isolate in the home, or does the discharge team need to help them with other accommodations? The discharge process will be affected by COVID-19 for many months to come – communication and education remain key.  

A Team That Has Your Back

The goal of discharge planners is to provide a safe discharge plan, sturdy enough to ensure that readmission isn’t likely. Early, honest communication between caregivers, the care team and discharge planners is essential to that process. And as you go home, remember that SMART acronym. Missteps happen when communication is weak or a patient modifies their care plan without discussing it with their provider. Discharge planning is complex, but you should never feel alone as a patient or caregiver. A whole team has your back. 

Discharge planning is the process of transitioning a patient from one level of care to the next. Ideally, discharge plans are individualized instructions provided to the patient as they move from the hospital to home or instructions provided to subsequent healthcare providers as they move to a longer-term care facility.[1] In the United States, discharge planning is required for hospital accreditation.[2] The goal of adequate and efficient discharge planning is to improve a patient's quality of life by ensuring continuity of care and reducing the rate of unplanned readmissions and/or complications, which may decrease the healthcare system's financial burden.[3][4] 

Increased life expectancy in the general population has led to an increased incidence of people living with chronic diseases and hospitalizations. The management of chronic conditions directly correlates with a patient's quality of life.[5] Due to the increased frequency of hospitalization of more complex patients, the discharge phase often comes earlier in their care and is much more important to the quality of the care they receive. A discharged patient is expected to be able to take medications as directed, continue to perform daily activities, and have the means to follow the plan for outpatient care, which may include rehabilitation programs, further testing, follow-up appointments, and/or lifestyle modifications. The lack of adequate discharge planning and failure of any of these elements can result in readmission and decreased quality of life.[6]

Before releasing a patient from the hospital, it is a requirement that the discharge can be completed safely.[7] Assessment for safe discharge by the physician involves several key factors that determine whether the patient will meet the requirements to heal and maintain health outside of a hospital setting. These key factors include the patient's physical ability to follow discharge instructions and perform activities of daily living, the patient's psychological ability to understand and follow discharge instructions, and a support system and financial means to obtain the appropriate follow-up care.[8] 

Institutions with high rates of readmission incur financial penalties, which include reduced or no reimbursement for readmission visits.[9] Comprehensive discharge planning is one element of a strategy that can help prevent readmissions. Although there are currently no standardized rules or regulations, patient safety and clinical outcomes remain the primary goals of discharge planning.[2] 

Patients with multiple chronic illnesses are more likely to be hospitalized, and coordinating their care after discharge can be challenging.[10] Discharge planning uses an interprofessional approach to provide additional support when patients experience changes in their health status caused by a new medical condition or worsening of a chronic medical condition complicated by other co-morbid diseases.[11]

Specific patient populations may require robust and meticulous discharge planning. For example, elderly patients, patients admitted for psychiatric treatment, and those who experienced major life events like myocardial infarction, cerebrovascular accidents, or major surgical procedures will require a more robust discharge plan. Such patient populations will often require additional coordination of care with rehabilitation facilities, long-term care, or home health care, as these services may increase the patient’s quality of life and reduce the rate of re-admission.[10][12] 

The implementation of electronic health records (EHR) has streamlined the process of discharge planning. An EHR is shown to facilitate communication between providers, and many have the ability to coordinate patient care between clinicians and facilities.[4][10] Most EHR systems consist of built-in educational materials for patients that are easily printed and provided with the discharge summary.[10] These educational materials often contain an explanation of the diagnosis, information regarding prescribed medications, and the laboratory and imaging results from the hospitalization. The customization of an EHR allows the physician to address the various needs of the patient with greater ease.

To discharge patients to their homes where they can heal and recover, it is imperative to perform an assessment of their home situation, caregiver support, and access to necessary follow-up care. By assessing their home situation, you must factor in their mobility, ease of food preparation, toileting, and other activities of daily living. In the event that the patient requires ongoing medical care that may not be available at the current facility or at home, the patient may need to be discharged from the inpatient service to a facility where this care can be provided.[5]

Effective collaboration is the key to successful discharge planning. The discharge planning process involves an interprofessional team approach. Physicians are responsible for deciding the patient is safe for discharge, creating the discharge plan in conjunction with the rest of the team, and communicating instructions to the discharge nurse or designated discharge personnel.[13] While having a well-thought-out discharge plan is important, it is just as critical to communicate this plan to the necessary providers as well as the patient. By communicating the discharge plan effectively to the patient, the provider can impact the quality of care the patient receives.[10] This is particularly important for elderly patients who will likely have a more complex discharge plan and require more assistance in executing the necessary elements of their plan. Discharge planning may include nurses, therapists, social workers, patients, family members, physicians, occupational and physical therapists, case managers, caregivers, and at times, insurance companies.[7] Each patient's discharge plan is customized to their own particular situation and may not necessarily involve all of these specialists.

The effectiveness of discharge planning is difficult to evaluate due to the complexity of the intervention and the numerous variables involved.[14] The quality of discharge planning correlates with a lowered readmission rate within 30 days, which directly affects reimbursement from Medicare and Medicaid.[15] [Level 2] In the United States, efforts by The Department of Defense to implement TRICARE will allow patients to consolidate their personal healthcare information to create their own healthcare homepage.[10] This can potentially help the patients and future caregivers to understand the patient's follow-up plan. Furthermore, the information provided to the patient at the time of discharge fosters better communication between the physicians, patient, and their families.[16] [Level 3] Patient loyalty to return to the same hospital for readmission is associated with the quality of discharge planning.[15] [Level 2]

Review Questions

1.

An D. Cochrane Review Brief: Discharge Planning from Hospital to Home. Online J Issues Nurs. 2015 Mar 12;20(2):13. [PubMed: 26882432]

Hunter T, Nelson JR, Birmingham J. Preventing readmissions through comprehensive discharge planning. Prof Case Manag. 2013 Mar-Apr;18(2):56-63; quiz 64-5. [PubMed: 23241896]

Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016 Jan 27;(1):CD000313. [PMC free article: PMC7073416] [PubMed: 26816297]

Gholizadeh M, Janati A, Delgoshaei B, Gorji HA, Tourani S. Implementation Requirements for Patient Discharge Planning in Health System: A qualitative study in Iran. Ethiop J Health Sci. 2018 Mar;28(2):157-168. [PMC free article: PMC6016349] [PubMed: 29983513]

Nunes HJ, Queirós PJ. Patient with stroke: hospital discharge planning, functionality and quality of life. Rev Bras Enferm. 2017 Apr;70(2):415-423. [PubMed: 28403308]

Zurlo A, Zuliani G. Management of care transition and hospital discharge. Aging Clin Exp Res. 2018 Mar;30(3):263-270. [PubMed: 29313293]

Rodakowski J, Rocco PB, Ortiz M, Folb B, Schulz R, Morton SC, Leathers SC, Hu L, James AE. Caregiver Integration During Discharge Planning for Older Adults to Reduce Resource Use: A Metaanalysis. J Am Geriatr Soc. 2017 Aug;65(8):1748-1755. [PMC free article: PMC5555776] [PubMed: 28369687]

Galvin EC, Wills T, Coffey A. Readiness for hospital discharge: A concept analysis. J Adv Nurs. 2017 Nov;73(11):2547-2557. [PubMed: 28440958]

Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission rates: current strategies and future directions. Annu Rev Med. 2014;65:471-85. [PMC free article: PMC4104507] [PubMed: 24160939]

Burton LC, Anderson GF, Kues IW. Using electronic health records to help coordinate care. Milbank Q. 2004;82(3):457-81, table of contents. [PMC free article: PMC2690228] [PubMed: 15330973]

McMartin K. Discharge planning in chronic conditions: an evidence-based analysis. Ont Health Technol Assess Ser. 2013;13(4):1-72. [PMC free article: PMC3804053] [PubMed: 24167538]

Chung DT, Ryan CJ, Hadzi-Pavlovic D, Singh SP, Stanton C, Large MM. Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2017 Jul 01;74(7):694-702. [PMC free article: PMC5710249] [PubMed: 28564699]

Bray-Hall S, Schmidt K, Aagaard E. Toward safe hospital discharge: a transitions in care curriculum for medical students. J Gen Intern Med. 2010 Aug;25(8):878-81. [PMC free article: PMC2896603] [PubMed: 20443072]

Mabire C, Dwyer A, Garnier A, Pellet J. Meta-analysis of the effectiveness of nursing discharge planning interventions for older inpatients discharged home. J Adv Nurs. 2018 Apr;74(4):788-799. [PubMed: 28986920]

Henke RM, Karaca Z, Jackson P, Marder WD, Wong HS. Discharge Planning and Hospital Readmissions. Med Care Res Rev. 2017 Jun;74(3):345-368. [PubMed: 27147642]

New PW, McDougall KE, Scroggie CP. Improving discharge planning communication between hospitals and patients. Intern Med J. 2016 Jan;46(1):57-62. [PubMed: 26439193]