Discharge Planning

Kathryn Murphy
2017

Example of discharge
https://www.youtube.com/watch?v=brLA5dnaGDU

Safe and Timely Dismissal from the Hospital

Begins on admission
A patient right
Early assessment
Prevent readmission
Regulated/Mandated
Foster independence
Coordinate health
care
Discharged to the
correct environment

Nurses role with Discharge

Planning
Identification/Assessment
Functional ability
Mental emotional
Financial
Support system

Offer resources
Education

Assessment of health literacy

Documentation

Content of teaching
Patient and family response to teaching
Condition at discharge
Referral agencies contacted

Discuss with the patient and family

prevent
problems at home.

key areas to

Describe what life at home will be like Include home environment, support
needed, what the patient can or cannot eat, and activities to do or avoid.
Review medications Use a reconciled medication list to discuss the purpose
of each medicine, how much to take, how to take it, and potential side
effects.
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.
Explain test results to the patient and family. If test results are not
available at discharge, let the patient and family know when they should
hear about results and identify who they should call if they have not
heard the results by that date.
Make follow-up appointments Offer to make follow-up appointments for the
patient. Make sure that the patient and family know what followup is
needed
Educate the patient and family in plain language about the patients
condition, the discharge process, and next steps at every opportunity
throughout the hospital stay
Assess how well doctors and nurses explain the diagnosis, condition, and
next steps in the patients care to the patient and family and use teach
back
Listen to and honor the patient and familys goals, preferences,
observations, and concern

Areas to Consider
Nutrition and Fluids
Medications
Therapeutic Measures
Activity Limitations/Restrictions
Home Environment
Support Systems
Financial Resources
Emergency Resources
Community Resources

Problem Identification
Are changes from the current arrangement
necessary?
What does the patient prefer to do?
Does the patient have significant others
who will help?
Is the patients residence compatible
with the current problem?
Can the patient return to the prehospital situation?
What services can the patient afford?
Is there evidence of abuse or neglect?
What community services are available?

Discharge example

https://www.youtube.com/watch?v=Un7As1R2-HU

Documentation
Summary of Admission
Prescriptions
Patient Education

Case Example
68 year old female
Fractured right hip
Lives alone
Lives in a second floor apartment

Potentially Complex DC Planning

Over 65 years and lives alone
Developmentally disabled
Suspected abuse or neglect
Admitted from other facility
No known address, lives outside area
No insurance/unemployed
Readmission within 30 days
Attempted suicide
Diagnosis consistent with chemical dependency
No ID
Lack of support system
Victim of violent crime
Diagnosis of catastrophic illness or injury
Multiple Trauma
Chronic disease
Home care or hospice

Who is part of the Team?

Provider
RN/RN Discharge Planner

Social Worker

Speech Therapist

Occupational Therapist

Dietician

Nurse Educators

Pharmacist

Physical Therapist

What should you do if you do not feel

comfortable with discharging a
patient?

Notify the MD immediately.

CASE MANAGEMENT

What is it?

Coordinating and allocating services for clients to

enhance continuity and appropriateness of care
developed in response to client needs and problems.
(Delmars Complete Review)

Similar to nursing processAssess, Plan,

Implement and evaluate

Case manager individualizes care and

collaborates with others to assure care

Assist patient to understand stand

resources available

Community Based Care

Facilities

Skilled Nursing Facility (SNF):

Intermediate Nursing Facility (INF)

Acute Rehabilitation Unit

Assisted Living Facility (ALF)

Residential Care Facility (RCF)

Adult Foster Home

Adult Day Care

OBRA

Omnibus Budget Reconciliation Act (OBRA)

of 1993. A Federal law that mandates the
quality of care at nursing facilities.
The patients bill of rights comes from
OBRA.

Part of Medicare

Potentially Complex DC Planning

Over 65 years and lives alone
Developmentally disabled
Suspected abuse or neglect
Admitted from other facility
No known address, lives outside area
No insurance/unemployed
Readmission within 30 days
Attempted suicide
Diagnosis consistent with chemical dependency
No ID
Lack of support system
Victim of violent crime
Diagnosis of catastrophic illness or injury
Multiple Trauma
Chronic disease
Home care or hospice