Effective discharge planning defined
By Diane Holliman, PhD, LCSW, Associate Professor, Division of Social Work, Valdosta State University, Valdosta, GA
In this age of evidence-based practice and cost containment in health care, effective discharge planning is increasingly important. But how is effective discharge planning defined and measured?
For this article, the academic nursing database (CINAHL) and the social work database (Social Work Abstracts) were used to find research articles defining and describing effective discharge planning. The articles in these databases are reviewed by authorities in their fields before publication, and reflect the results of qualitative and quantitative studies on discharge planning. These databases may be accessed through university and other public libraries so all those doing discharge planning may have access to them.
The term "discharge planning" did not appear in the academic or professional literature until the 1970s; however, the process of discharge planning in health care, social work, and nursing has a long history that includes urban hospitals clearing their wards of chronic patients and homeless Civil War veterans during the 1890s, child welfare organizations protesting the indiscriminate placement of infants who were abandoned by their mothers during the early 1900s, and the deinstitutionalization movement in mental health of the 1960s.
In the 1970s, with advances in medical treatment, technology, and medications, health care costs began to steadily increase.
In the 1980s, prospective payment plans such as diagnosis-related groups (DRGs) were put into place to contain health care costs. These prospective payment and managed care systems required prompt patient discharges and reduced length of stays for hospitals to maintain their financial viability. Thus, discharge planning emerged as an important function in the hospital setting.
Discharge planning: Many names and purposes
Today there are various definitions of discharge planning and terms that are synonyms for discharge planning. However, there is some agreement that:
- Discharge planning is a complicated, dynamic, multidimensional, and multi-task process;
- Today, many individuals and organizations (patients; caregivers; health and mental health professionals; community organizations; private, for-profit outpatient health care providers; insurance companies; Medicare; and Medicaid) have a stake in discharge planning;
- These individuals and organizations often have competing interests and objectives.
Terms that have been linked to discharge planning or that are closely associated with discharge planning are "care transitions," "relocation management," "transitional care," "continuity of care," "coordination of care," and even "premature termination" and "patient dumping."
Among professional discharge planners, there is a maxim that "discharge planning begins the day of admission." However, today we are seeing that effective discharge planning should start before admission and can be as important in a person's preplanning as a living will or organ donation.
For example, a 74-year-old female with congestive heart failure may come into the hospital with "Plan A" and "Plan B" for discharge. "Plan A" may be to return home with housekeeping assistance if she is continent and able to ambulate after the hospitalization. "Plan B" could be to be discharged to her daughter's home with home health care and home physical therapy if she is incontinent or unable to ambulate.
For this patient, as well as many others, there may be a need for a "Plan C" or "Plan D." There are often multiple variables that affect individuals' dispositions when they are ready to leave the hospital (financial status, community resources, available caregivers, severity of their medical condition, functional abilities).
Today, discharge planning includes more than just discharge from an inpatient hospital setting. Patients today are commonly discharged from nursing homes and outpatient hospices because of their physical improvements or the increased confidence and education of the patient and caregivers. Discharge planning should be a part of outpatient surgery admission and community mental health. Discharge planning, short and long-term planning, or even "life planning," as some call it should be a comprehensive process that involves medical, functional, psychological, social, financial, community, and organizational assessment and referral.
A challenge to measure
Because of the multiple and changing factors that influence discharge planning, effective discharge planning can be challenging to measure. Measures for effective discharge planning have included:
- length of stay;
- patient/caregiver satisfaction;
- readmission or recidivism rates;
- cost of hospitalization or treatment;
- amount of time spent discharge planning by staff;
- documentation of the tasks done by discharge planners
However, none of these factors alone define effective discharge planning.
Effective discharge planning remains a fuzzy concept. The products of effective discharge planning are seamless, invisible, and silent, whereas ineffective discharge planning can lead to extended lengths of stay, patient/caregiver dissatisfaction, readmissions, malpractice, and higher health care costs.
The academic and research literature describes factors that adversely affect discharge outcomes. Patients whose conditions or situations are atypical or non-routine may have less successful discharge outcomes. These atypical or non-routine situations may include:
- severity of illness or disability;
- chronic and persistent mental illness;
- language barriers;
- substance abuse;
- absent or inconsistent social support;
- patient inability or refusal to follow treatment plans or staff directives;
- financial, housing, and insurance barriers.
Other barriers include institutional and community limitations such as conflicts between the patient's rights and managed care requirements, the temptation to manipulate diagnosis to prolong length of stay, limited community resources, lack of discharge planning by the treatment team, and a lack of awareness of the biopsychosocial factors affecting the patient and his or her caregivers.
Predictors that lead to effective discharge planning are high-risk screening for discharge planning; preadmission planning; biopsychosocial assessment as part of treatment and discharge planning; involvement of patients, caregivers, and community in the planning; development of literature and other educational tools for discharge planning; and scheduling post-discharge phone calls for follow-up.
Discharge planning is a process that takes place throughout the course of a person's treatment and care. Recommendations for successful discharge planning on the individual level are to take a comprehensive biopsychosocial approach to discharge planning, and to involve patients, caregivers, and the community in the process.
On the macro level it is important to look at organizational, community, state, and national policies that affect discharge. Can programs be developed to educate patients and caregivers on discharge treatments and community resources? Are there state and federal policies that may adversely affect patients in your setting? How can you educate your patients and policy-makers?
Collaborating with organizations, contacting your legislators with specific examples of how policies are problematic while insuring patient confidentiality, supporting outcome-based research, and building community networks can lead to effective discharge planning not just for one patient or caregiver, but for patients and caregivers over time.