Discharge Planning

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Introduction

Discharge planning is an important element in preventing adverse events post discharge. Around 20 percent of patients experience an adverse event within 30 days of discharge, with a reported median of 27% of hospital readmissions being avoidable, and in some cases this was as high as almost 80%.

Common post-discharge complications include adverse drug events, hospital-acquired infections, and procedural complications. By involving the patient and family in discharge planning patient outcomes can be improved, readmission reduced and an overall increase in patient satisfaction.

The video below goes into good detail the discharge planning process and outlines 3 basic discharge plans. The basic, the moderate and the complex discharge plan, detailing what is involved in each.

IDEAL discharge planning

The key elements of discharge planning are incorporated in the IDEAL discharge planning

I

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

D

1. Discuss with the patient and family five key areas to prevent problems at home:
2. Describe what life at home will be like
3. Review medications .
4. Highlight warning signs and problems .
5. Explain test results .
6. Make followup appointments

E

Educate the patient and family in plain language about the patient’s condition

A

Assess the patient's understanding of the discharge plan. This step is vital to confirm that the patient understands what the medical team, including doctors and nurses, has told them. If necessary, explain the diagnosis, condition, and next steps in the patient’s care to the patient and family again. This will ensure that the patient and their family are adequately equipped with the knowledge required for post-discharge care.

L

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

Checklist of items for favourable discharge from hospital.

Anticipated Time and Date of Discharge

1. Establish the expected time and date of discharge to identify potential problems which may effect the patient’s discharge.
2. Provide details to the patient, their family and carer.

Carers

• Determine if the patient has a carer (e.g. family member, friend, neighbour, other).
• Check the carer is happy to assist and capable.

Mobility and Independence

If there are concerns regarding post-discharge independence or safety, consult a Physiotherapist or other relevant allied health professional e.g. OT, Respiratory Physician, Podiatrist, Dietician, Speech Pathologist. Check use of aids and appliances, and the need for any home modifications. Arrange instruction via eg physiotherapist on the use of aids or appliances as necessary.

Community Nursing

Confirm with patient/family/carer whether or not community nursing services are already in place. Forward a timely referral and discharge plan, with appropriate clinical information, to the community nursing agency.

Medication

Sufficient quantities of medication should be supplied until the next consultation. Check that the patient understands the purpose, dosage, frequency and side-effects of their medication, and that no confusion exists between past and present medications.

Recovery and Special Instructions

Outline expected recovery path and confirm understanding. Provide any necessary or special instructions in writing.

Medical Appointments

1. Arrange all necessary appointments
2. Provide the patient or carer with written details of the appointments.
3. Ensure relevant clinical information is provided to health professionals.

Nutrition

Discuss future nutritional needs and organise services to meet these if necessary.

General Practitioner

Arrange the issue of a discharge summary to the patient’s GP and referring doctor at the time of discharge, with a copy given to the patient / carer.

Patients Medical Records

Ensure the patient takes with them any private x-rays, scans, medical documents, medicines as well as all personal belongings.

Travel Assistance

Organise transport home and to follow-up appointments as early as possible.