Tips on long-term steps to improve discharge planning

Work with community partners too

When Spartanburg (SC) Regional Medical Center began a process to improve its discharge planning process, it began with improving collaboration from both within the hospital and within the larger medical community.

The hospital system has a long-term acute care hospital, and the goal was to improve collaboration with this facility, says Angie Roberson, RN, BSN, CPUM, director of case management.

Previously, hospital staff had the attitude that the long-term care facility wouldn't take some patients, and there were misunderstandings about why this occurred, Roberson notes.

"It was an 'us' against 'them' kind of thing," she says. "We've overcome that to the point where case managers now work off the same piece of music."

Case managers now accept the fact that sometimes the long-term care facility cannot take certain patients, because it's not appropriate, Roberson says.

Here are more examples of how the hospital has improved its discharge planning and collaborations:

• Develop a good relationship with nursing home staff: "We also have a nursing home collaboration, and we have the same spirit with our outside partners as we do with other hospital units," she adds. "We place a lot of patients in nursing homes, so we have to have a good relationship with nursing home staff."

The hope is that if hospital professionals working in discharge planning treat the nursing home staff well, then this will make an impression and lead to a better collaboration in finding beds for hospital patients, Roberson says.

"If you want them to work with you, they need to know you and feel like you're there for them — it's all about collaboration," she explains. "So, we try to employ that collaborative spirit."

So far, the collaboration between the hospital and nursing home has led to success in decreasing the LOS of patients transitioning to the nursing home, Roberson says.

• Designate a liaison between hospital and nursing homes: "We have one geriatric case manager who is a liaison between us and the nursing homes," Roberson notes. "This case manager doesn't carry a case load, but she works with unit-based discharge planners, coordinating between them and nursing homes."

For example, the liaison case manager stays up to date on data related to nursing home placement.

"Each day, the nursing homes send out a list in an e-mail, saying, 'I have this many female and male beds available,'" Roberson explains. "Based on that list, we know what's available when we work with our patients every day."

When the hospital has a complex patient to transition, the liaison case manager will call the nursing homes and describe the patient's situation to find the best place to transition the patient.

The key is the liaison knows the facilities first-hand.

"She knows which place works well with dementia populations and which do well with wound care," Roberson says.

Her work helps both the hospital and nursing homes, because her advance information gives nursing homes a better picture of the patients they'll be seeing, she adds.

• Improve communication with physicians and families: Discharge planning nurses and case managers need to be sure they're communicating regularly with physicians, Roberson says.

They need to ask a physician when he or she anticipates a particular patient will be ready for discharge, she adds.

"We have to keep physicians involved," Roberson says. "It's all about communication and having everybody on the same page."

This also means that discharge planners should keep patients and families abreast of their plans, including them in the discharge planning process, she says.

Part of improving communication is learning the ways to express transitions and discharges without raising concerns in patients and families.

For instance, discharge planners should frame the discharge planning process in terms of improving patients' quality of life.

They might say to a patient: "It's important to us that we get you better as soon as possible and get you back home to your regular routine as fast as possible," Roberson suggests. "So, at the very beginning, we talk about what they're going to need at discharge, so they won't think we're trying to kick them out before they're well."

• Keep a communication board in each patient room: "We want to have dry-erase boards in every patient room, so we can put on their anticipated discharge date," Roberson says. "It's a challenge, and we haven't quite gotten there yet."

When discharge planners use this method to keep the discharge goal in everyone's mind, then it'll be even more important to be careful about how this is discussed with patients, she notes.

The idea behind the dry-erase boards is to keep the discharge date visible to family members, so they can make plans and juggle their schedules to be available on the day when their family member is returning home.