Are your hospital's discharges really effective?

Comprehensive assessment integral

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Effective patient discharge is a priority area for all hospitals. Yet many patients who returned home after their hospital stay believe their discharge was inadequate in terms of the information they received and the information sought about their need for assistance at home.

Continuity of care is particularly important for people who have ongoing needs for care. In-hospital care planning processes must have the capacity to discriminate and respond to differing levels of need for coordination and post-discharge care. Discharge planning serves as the critical link between treatment received by a patient in the hospital and post-discharge care provided in the community.

Joint Commission standards require that discharge planning start as soon as possible. This may be prior to admission (for planned admissions) or at the time of admission (for unplanned admissions). Because proper discharge planning is important — even for patients who will be returning home — hospitals should have mechanisms to regularly evaluate compliance with the standards as well as the effectiveness of the process.

Discharge planning requires a systematic, problem-solving team approach. All members of the health care team need to be involved in one or more steps of the process:

  • Assessment of patient physiological, psychological, social, and cultural needs.
  • Care plan development — identifying and documenting discharge strategies as part of an integrated planning process.
  • Implementation of a plan — arranging for the provision of services, including patient/family education and referrals.

Discharge planning begins with, and is contingent on, a thorough, accurate, and complete assessment by all those involved with the patient in hospital. This comprehensive assessment requires an understanding of the patient's home and social circumstances, such as:

  • available family resources and preferences for post-hospital care;
  • cultural, linguistic, and religious needs;
  • home environmental impediments to recuperation;
  • existing responsibilities not being met due to admission;
  • capacity to perform activities of daily living;
  • the community services that were used before admission and likely to be needed on return home.

Sources of information include the patient, family, patient's physician, and other community providers that delivered services and care to the patient prior to admission. An assessment of the patient's post-discharge needs may also involve a home visit by hospital staff, such as the occupational therapist, to assess the environment to which the patient will be discharged.

Screen and care planning

Many patients returning home from the hospital have no continuing care needs and do not require a comprehensive assessment or plan. Often the pre-admission or admitting nurse can determine whether a patient falls into this low-risk category and referral to a case manager is not necessary. Screening criteria should be used by the nurse to identify patients in need of more comprehensive discharge planning and service provision to support their return home. The use of risk screening tools ensures that case management resources are used only for the most appropriate patients.

A plan of care must be developed to address potential problems that patients will face upon leaving the hospital. This plan encompasses treatment needs identified by physicians, nurses, and allied health professionals. Even if the patient is not seen by a case manager, a plan of care is still required and it should be written in a way that allows for quantitative analysis of the patient's progress against expected outcomes.

The patient and family must be actively involved in the care planning process. This ensures that their needs and preferences are taken into account. Another group that should be considered during care planning is the community providers that may be needed to meet the patient's post discharge needs. Consideration should be given to:

  • The suitability and capacity of community providers to meet the post-discharge needs of the patient in terms of expertise and resources.
  • Timing discharge to coincide with the operating hours and availability of community services.
  • Providing adequate notification to community providers to ensure that services will be in place by the estimated discharge date.

Coordination and implementation of discharge activities can start as soon as the care plan is developed. Certain services may be initiated even before the patient's admission. The patient and family should receive information and education about:

  • the anticipated course of treatment and discharge date;
  • ongoing health management;
  • an appropriate post-discharge contact to answer queries and address concerns;
  • medications (including reconciliation);
  • the use of aids and equipment;
  • follow-up appointments;
  • community-based service appointments;
  • possible complications and warning signs;
  • when normal activities can be resumed.

Referrals must be made to outpatient services (such as radiology, pharmacy, occupational therapy) and external agencies or services (such as Meals on Wheels, home health care, maternal and child services). These referrals should occur as soon as the patient's expected date of discharge is known, to be certain that the transition from hospital to home goes smoothly. If case managers are not available to make these arrangements, staff nurses or another member of the health care team should be responsible. On the day of discharge, everything should be set for the patient's expeditious and seamless return to home.

Post-discharge evaluation

Ideally, the hospital conducts some level of post-discharge evaluation. The purpose of following up on a patient after they have left the hospital is two-fold:

  • To evaluate the impact of the planned interventions on the patient's recuperation and possibly identify recurrent and new care needs.
  • To assess the effectiveness and efficiency of the discharge process.

Follow-up of patients post-discharge (either via telephone and/or contact with the patient's physician or other community providers) provides the opportunity to find out if the problems identified as requiring intervention post-discharge were adequately addressed and to deal with any new problems. It also provides the opportunity to reinforce teaching initiated in the hospital and provide assurance to the patient and their home caregivers. This part of the discharge process is key to ensuring continuity of care.

The expected outcomes identified on the care plan should form the basis for questions to be asked of the patient. For example, if an exercise regime was initiated for the patient while in the hospital, this person would be asked if they are exercising and if their range of motion is improving. In addition to questions specifically related to care outcomes, the following questions may be asked to gauge the effectiveness and efficiency of the discharge process:

  • How are you coping?
  • Do you have any questions?
  • Have you received the services arranged by the hospital and when?
  • Is your family or other caregiver able to provide adequate support?
  • Have you visited another hospital or the emergency department since discharge?
  • Have you received services other than those arranged by the hospital?
  • Were you satisfied with your hospital discharge and post-discharge care?

Evaluation and follow-up provides the opportunity to evaluate not only the effectiveness of the discharge process, but also the effectiveness of the interventions set in motion by hospital caregivers. There are clear benefits in practicing effective discharge, such as improved efficiency, better health outcomes, and improved satisfaction for patients. An ongoing evaluation of the hospital's discharge planning process allows caregivers to identify strengths and weakness.