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Who do the changes apply to?

The discharge planning process applies to inpatients, specific emergency department patients, and same-day surgery and outpatient observation patients. A qualified person must coordinate the discharge needs evaluation and discharge plan. Identification of anticipated discharge needs must begin within 24 hours of admission. The discharge planning process must be done before the patient is discharged home or transferred to another facility such as a long term care facility.

Some hospitals perform a discharge planning evaluation for every patient. For some patients it may be as simple as explaining discharge instructions and having the patient repeat them. The social worker or discharge planner reviews the chart daily to determine if there is any change in the patient’s condition. Hospitals that do this will prevent jumping through many of the hoops in the discharge process. The proposed regulations state that the discharge process regularly reevaluates the patient’s condition to identify any changes that would require modification of the discharge plan.

The physician or practitioner responsible for the patient’s care must be involved in the process or establish the patient’s goals and preferences. Many times it is an interdisciplinary committee that is involved.

Here’s an example. A patient has suffered a severe stroke. The patient wants to go to a rehab center near home. The patient wants to be ambulatory without using a walker or cane. The interdisciplinary committee is composed of the attending physician, the pharmacist, nurse, social worker, dietician, physical therapist, and occupational therapist. Also included was the patient’s support person or patient advocate.

In the discharge planning process, the hospital must consider the patient, caregiver, or support person’s ability to perform necessary care. The patient has a wound dehiscence after surgery and must pack the wound and apply a dressing. The patient is also going to be discharged with a Jackson Pratt drainage tube and a Foley catheter. The patient decides to go home with the assistance of a home health nurse and the support person.

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