Early discharge planning improves throughput

Involve the family from Day 1

The key to avoiding emergency department boarding is to move patients through the continuum as quickly and safely as possible. That’s where case managers are essential in making sure the stay goes smoothly, that patients’ discharge needs are identified early in the stay, and that patients and family members are aware of the anticipated discharge day.

“Facilities are finding that some patients still expect to stay in the hospital as long as they want to stay or until it’s convenient for someone to arrive to take them home. It’s up to the case managers and social workers to anticipate their discharge day and discharge needs and make sure the patient and family understands,” says Brenda Keeling, RN, CPHQ, CPUR, president of Patient Response, Inc., a Durant, OK-based healthcare consulting firm.

Once the clinical discharge plan has been determined, the social worker and case manager should communicate the plan to the patient and family to arrange discharge needs and make certain that the patient and family understand the plan, she adds.

Avoid “just in time” discharge planning and start to identify patients’ discharge needs while they are still in the emergency department, or as soon as they are admitted to an inpatient bed, advises Tonya Kirby, BSN, MHA, MBA, senior director quality and safety collaborative for the Premier healthcare alliance.

Always include the patient and family in the discharge plan. “Case managers should have open communication with patients and families,” Kirby says. Discuss the plan of care for the patient, the anticipated length of stay, and likely discharge needs.

If family members are not in the patient room when you visit, call them and let them know what’s going on with the patient and the plan of care. Case managers should be well informed about the patient’s living situation, support system, and post-discharge needs, and not just find out on the day of discharge, Kirby says. Determine if a patient will need durable medical equipment, physical therapy, or home health services after discharge and get it ordered early in the stay. Start talking to the patient and family about what kind of care the patient will need at home after discharge so the family can arrange everything in advance, Keeling suggests.

Don’t wait until the day of discharge to tell the family of the need for post-acute care. For instance, if a patient is likely to need a stay in a rehabilitation facility or skilled nursing facility, tell the family on Day 1 so they’ll have time to check out potential facilities.

“Work closely with the multidisciplinary team so everyone caring for the patient is informed,” Keeling suggests. Place a dry-erase board in each patient room and have the staff update it throughout the day. Include the names of the nurses, case manager, and social worker, the procedures scheduled for that day, and the anticipated day of discharge. Back that up with a script that everyone who cares for the patient uses to emphasize the expected length of stay and the need to prepare for discharge.

For example: “I see you’re here for a hip replacement. The average length of stay is three or four days. Some patients may be ready for discharge earlier and some may take a day or so longer. However, we try to provide our patients with the anticipated discharge date so you and your family will have time to make arrangements to go home with assistance or, if your physician recommends it, you may have a short stay in a skilled nursing or rehabilitation facility.”

Case managers need to change the way they look at patients and think about the entire stay, rather than what has to be done in the next hour or day, Kirby says.

“Because we have had such a shortage of healthcare providers, we have educated them to be task-driven and not think about why the patient is here, what the plan of care is and why the patient is receiving that particular care,” she says. Start the discharge assessment teaching when you see the patient for the first time. For instance, if a patient is starting on new medication, start talking about it, the cost, and whether the patient can afford it or whether you should get social work involved.

Consider having bed huddles more than once a day, such as on both the first and second shift on all units. Determine the barriers to a timely discharge and concentrate on eliminating them. For instance, if patients who no longer meet inpatient criteria can’t be discharged because there isn’t a skilled nursing bed available or they don’t have anyone to take care of them at home, it may be that the discharge planning process needs to start earlier. “If you can’t get patients out of the hospital, you can’t get anybody else in,” Kirby says.

During the bed huddles, look at who has a discharge order and work on getting them out. Once you determine who could be discharged that day, work with the physicians to expedite discharges, Kirby says.

Kirby adds:

  • Make sure that patients on your unit are in the right level of care and that beds that can be open are open.
  • Look at patients in the intensive care unit or step-down units to determine if they can be moved to a medical-surgical unit.
  • See that patients get discharged and out the door as early in the day as possible.
  • Remember that change-of-shift is a difficult time for moving patients from one place to another and try to plan your discharges accordingly.