The Quality-Cost Connection: Improve your discharge planning effectiveness
Patient and caregiver involvement is key
By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR
With the decline in average hospital lengths of stay, discharge planning has become more challenging. Many hospitalized patients have complex care needs, and they are particularly in need of comprehensive discharge planning.
Because of changes in treatment practices, consumers increasingly view hospitals as one component of a broader health care system. They expect to be adequately prepared for hospital discharge and offered sufficient post-hospital support.
Care previously provided in the hospital is now provided in the community.
This shift demands an integrated approach to the planning and delivery of services to ensure continuity across provider boundaries. Discharge planning operates as an important interface between acute care and a wide variety of post-hospital support services.
To facilitate continuity of care, hospital discharge protocols need to be developed with the active involvement of physicians, post-hospital care providers, and other community support agencies.
Involving caregivers and community
To meet the varied needs of patients, care-planning processes must have the capacity to discriminate and respond to differing levels of service coordination and post-discharge care.
Effective discharge planning is based two important principles:
1. Patient and caregiver involvement.
The patient, family, and other responsible caregivers should be actively involved in the care planning process. This ensures that their needs and preferences are taken into account. Involving the patient, family, and caregivers requires ongoing communication about the patient’s condition, treatment options, associated risks, and anticipated outcomes.
2. Community provider involvement.
An important determinant in discharging patients on the day planned is the capacity of the attending physician and post-hospital providers to be able to meet the patient’s care needs. For this reason, the patient’s physician and other providers must be actively involved in the development and execution of the patient’s discharge plan.
Hospital discharge cannot begin on the day a decision is made to send a patient home. Discharge planning must start prior to admission (planned admissions) or at the time of admission (unplanned admissions).
Effective discharge planning involves four stages:
- assessment;
- care plan development;
- implementation of care plan;
- follow-up post-discharge.
Appropriate interventions in each of these cycles help contribute to effective discharge planning. When evaluating the quality of discharge planning services, caregivers should measure completion of critical processes and attainment of desired outcomes.
Critical processes
Effective discharge planning is reliant on a thorough, accurate, and complete assessment by all those involved with the hospitalized patient. The discharge procedure for many patients leaving the hospital may be relatively simple and does not require an intense assessment or plan.
Case managers must have a way to identify patients in need of more comprehensive discharge planning and service provision to support their return home or transfer to another provider site. When an intense assessment is needed, the patient’s physiological, psychological, social, and cultural needs must be evaluated to gain a complete understanding of the patient’s home and social circumstances, such as:
- available family resources and preferences (e.g., whether the family/responsible caregiver is willing and able to provide the care and support needed);
- cultural, linguistic, and religious needs;
- home environmental impediments to recuperation;
- existing responsibilities not being met due to admission (e.g., child care, pets, work);
- capacity to perform activities of daily living;
- the health care and community services that were used before admission and likely to be needed on return home.
The plan of care should address specific strategies for meeting actual and potential problems that the patient will face upon leaving the hospital. In determining the estimated discharge date, the intensity and type of the patient’s ongoing needs for care and services have to be matched with the availability and capacity of the attending physician and other providers to respond.
Coordinating and implementing discharge activities can start as soon as the care plan is developed. Certain strategies may be implemented even before admission.
The activities related to preparing the patient for discharge include:
providing information and education to the patient and the family/other responsible caregivers in the appropriate language, verbally and in written form relating to:
— anticipated course of treatment and discharge date;
— ongoing health management;
— an appropriate post-discharge contact to answer queries and address concerns;
— medications;
— use of aids and equipment;
— follow-up appointments;
— community-based service appointments;
— possible complications and warning signs;
— day normal activities can be resumed;
• arranging referrals to hospital-based services (e.g., radiology, pharmacy, occupational therapy) and external agencies or services (e.g., Meals on Wheels, home health care, durable medical equipment, hospice);
• initiating two-way communication between the hospital and community providers to ensure services are in place for the patient to use when needed post-discharge;
• preparing and delivering vital information in the patient’s health record to the post-hospital care providers to assist them in organizing service delivery — including description of the unresolved, ongoing problems listed on the hospital care plan, key test results, and medication regime, emergency contact person, contact number, and availability;
• discussing the discharge information with patients to ensure they understand the care plan, medication regime, and so on;
• confirming transport arrangements from hospital to home or to other provider sites;
• contacting the family and/or other community providers to confirm that the patient is being discharged and to ensure that services are activated or reactivated.
The purpose of following up the patient after he or she has been discharged from hospital is to evaluate the impact of the planned interventions on the patient’s recuperation and possibly identify recurrent and new care needs. A secondary purpose is to assess the effectiveness and efficiency of the discharge process.
Follow up of patients post-discharge (either via telephone and/or contact with the attending physician and other caregivers) allows hospital case managers to determine 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 patients and their home caregivers.
Follow-up is vital to ensuring continuity of care for the patient. The expected outcomes identified on the patient’s care plan influence the questions to be asked. For example, if the hospital physical therapist instructs the patient on an exercise regime that is expected to produce an improved range of motion of a limb three days after discharge, the patient should be asked if he or she is exercising and if this result has been achieved.
In addition to questions specifically related to the patient’s individual condition, the following questions might be asked to gauge the effectiveness and efficiency of the discharge process:
- Are the patient and caregivers coping?
- Do they have any questions?
- Has the patient received the services arranged by the hospital case manager and when?
- Is the family or responsible caregiver able to provide adequate support?
- Has the patient visited another hospital, emergency department, or a physician since discharge?
- Has the patient received services other than those arranged by the hospital case manager?
- Was the patient satisfied with his or her discharge and post-discharge care?
The evaluation and follow-up stage of the discharge process provides the opportunity to evaluate not only the efficiency of the discharge process but also the effectiveness of the post-discharge interventions.
With reductions in hospital lengths of stay, well-organized discharge practices and processes are imperative. The public has become more accustomed to shorter hospital stays, and patients and families expect that the transition from hospital to home (or to another provider) will be as seamless as possible.
Ongoing monitoring of critical discharge planning processes and outcomes is an important part of the hospital’s performance management activities.
[Note: The newly released book, Measuring and Improving Continuity of Patient Care, will help you take a critical look at your discharge planning process. For ordering information, contact Brown-Spath Associates at (503) 357-9185 or visit the web site at: http://www.brownspath.com.]
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