Timely and comprehensive discharge planning helps with patient and/or family satisfaction and can assist with minimizing the number of re-admissions if the plan is the most appropriate for the patient, and includes detailed education & discharge instructions along with crucial information is shared with the next caregiver.
Key requirements supported by both The Joint Commission Standards and CMS Conditions of Participation include:
• Discharge planning is to be initiated upon admission- This is essential as we see the average length of stay shorten. The gathering of details about the patient, their support systems and their physical, emotional and social needs must start early in order to engage those external support systems needed for a safe discharge.
• Discharge Planning is to be based upon assessment(s) and reassessments on an ongoing basis, up till discharge- this is particularly important when we consider our most fragile patients such as our most elderly and our young, premature infants.
• Discharge Planning must include a multi-disciplinary approach with all the disciplines involved or needed as applicable to the individual patient’s identified needs. – As our healthcare delivery model continues to expand and telehealth services establish a firm foundation in our delivery model, the opportunity for multiple disciplines to keep a patient connected to the care team is now possible. Providing ongoing support related to nutrition, medication management, activities and other support systems will become easier to provide.
• Patient and family involvement are important, and planning should be based upon mutual goals- This is the most important component of the care plan. Ensuring that we are aligned with the patient’s wants and needs is essential for success.
• Hospital discharge planning must identify patients at risk of adverse events- upon discharge at an early stage of hospitalization and provide a discharge planning evaluation for identified patients that includes a patient’s likely need for post-hospital services.
When discharging or transferring, hospitals and home health agencies must assist patients in selecting a post-acute care provider. New to this process are new requirements within the CMS Conditions of Participation for 2020, that requires healthcare organizations to include quality measure data applicable to the patient’s care goals and treatment preferences for each post-acute care setting. This sharing of data with the patient is expected to assist patients and their families with making their selection of a post-acute care provider location. The sharing of this data is to be documented in the medical record.
The Agency for Healthcare and Quality (AHRQ) references a tool called "IDEAL" in IDEAL Discharge Planning which stands for:
• Include the patient and family as full partners in the discharge planning process.
• Discuss with the patient and family five key areas to prevent problems at home:
o describe what life at home will be like
o review medications
o highlight warning signs and problems
o explain test results
o make follow-up appointments.
• Educate the patient and family in plain language about the patient's condition, the discharge process, and next steps at every opportunity throughout the hospital stay.
• Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient's care to the patient and family and use teach back.
• Listen to and honor the patient and family's goals, preferences, observations, and concerns.’
References:
The Joint Commission Comprehensive Accreditation Manual for Hospitals 2020
https://courtemanche-assocs.com/cms-discharge-planning-worksheet/
https://www.medicare.gov/pubs/pdf/11376-discharge-planning-checklist.pdf
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-3.pdf
https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_1_IDEAL_chklst_508.pdf
