Discharge Planning is one of the most important functions that case managers and Board Certified Patient/Health Advocates perform.
Depending on where you meet your patient, an inpatient hospital or rehabilitation facility, an outpatient rehabilitation facility, a skilled care facility, or in the home, learning about the discharge plan is critical so you know the plan and the resources needed.
Talking to the patient and the facility case manager, social worker, or discharge planner about the discharge plan is important, as it gives you a sense of what the person will need in terms of resources and education.
Having the patient and their family involved in the plan is important for their buy-in and participation.
Here are some questions you can ask to make sure the discharge plan meets the needs of your patient:
- What is the condition of the patient? Are they able to do their activities of daily living themselves, or do they need help? If they need help, who will provide it?
- Can they walk, transfer from the bed, the chair, the toilet, and back to their bed alone, or do they need assistance? Can a family member be trained to do this? Can they take a shower? What equipment is needed to keep the patient safe in the shower?
- Is their home equipped to allow them to move through the home safely?
- Is there a way for them to get out of the house safely if there is a fire or other emergency?
- Does the home need modifications?
- Is the patient able to be alone in the home if the caregivers have to go to work? If not, it is not a safe discharge, and the patient should not be moved till a plan is developed to meet these needs
- Will the patient need therapies or services in the home, or can they go to outpatient therapy? If they go to outpatient therapy or doctors’ offices, do they have transportation? These will need to be set up with providers prior to discharge.
- What education does the patient need before they go home? Do they understand what is wrong with them? Do they know their diagnosis? Do they understand and agree with the plan of care? What questions do they have surrounding the diagnosis?
- What medications will they need to take once they go home? Has a medication reconciliation been done with the medications they were on to the medications they are going home on? Do they have the means to get their medication?
- What equipment do they need at home? Has the patient/the family been taught how to use it? Do they understand the importance of using the equipment?
- Who will follow the patient once discharged? What are the red flags the injured worker/family should be aware of?
- When does the patient need to see his primary care doctor, specialists, or go for tests or treatments? Who will set each up?
- The discharge plan is not a one-time event. Once the injured worker is discharged, they will have ongoing needs that must be planned and addressed to support the patient/family. Who will the person be to follow up, monitor, and adjust the plan of care? Is there an insurance case manager who will step in? Does the patient/family have an advocate who will help them? Are they left to navigate alone?
A lot of responsibility is placed on the patient and their families during the discharge process. It is our role as members of the healthcare team to help them be prepared and ensure a safe discharge.
Each of these questions is designed to help the patient, his/her family, and the healthcare team determine what is needed for discharge.
The number one question that needs to be answered prior to discharge: Is the discharge safe? This question must be answered before the patient leaves the setting. If they are not safe, then we need to look at Plan B.
I hope this article helps you plan each discharge to meet the individual needs of each patient you work with. Doing so will ensure safe discharges, prevent readmissions and injuries, and involve your patient and their families in the team.
What did I miss? Let me know, and I can include it in part two, when I talk about the issues patients and families should be aware of as part of the discharge process and the transition of care from one setting to another
Have a good week!
