Comprehensive Discharge Planning

Gap Analysis of Best Practices/Strategies for Improvement

Component / Best practice/Strategy / Present / Gap/Opportunity
Discharge Planning - Process / Conduct pre-discharge assessment of ability of patient/family to provide self-care (includes problem solving, decision making, early symptom recognition, and taking action, quality of life, depression and other cognitive and functional ability factors)
Develop a comprehensive shared care plan using a shared decision making approach – consider patient values and preferences, social and medical needs
Discharge summary and medication plan are complete and up to date
Work with patient/family to prepare for the post discharge visit planning (goals, questions, concerns)
Work with patient/family to complete advance directives as appropriate
Discharge Planning – Content / Written discharge plan includes the following:
  • Reason for hospitalization
  • Medications to be taken post discharge, including, as appropriate, resumption of pre-admission medications.
  • Self-care activities such as diet, activity level or limitations, weight monitoring
  • DME/supplies that patient will need for care
  • Symptom recognition and management – what to do if patient has a question, a problem arises or condition changes, including of symptoms of which to notify health care provider
  • Coordination and planning for follow-up appointments
  • Coordination for follow up of test and studies for which confirmed results are not available at the time of discharge.
  • Coordination of community resources patient will utilize, such as:
  • Home Health Care
  • Meals on Wheels
  • Adult Day Care
  • PT, OT, ST
The written discharge plan should be easy to read:
  • Include only essential education on health condition
  • Utilize plain language - clear, straightforward expression, using only as many words as necessary
  • Use universal principles of health literacy to specify reader-friendly written materials: simple words, large font, short sentences, short paragraphs, no medical jargon, headings and bullets, highlighted or circled key information, lots of white space, use visual aides

Care Coordination / Make appointments for follow-up and post-discharge testing, with input from the patient regarding time and date
Use personal health records or patient portals so patients have access to necessary information (lab results, radiology results, request prescription refills, ability to email doctors, nurses, and staff with questions)
All care providers have a complete discharge summary
All care providers know their care roles and responsibilities
Conduct post discharge telephone care management
Health Literacy/
Patient-Provider Communication / Educate the patient about diagnosis throughout the care continuum
Embed health literacy principles into all patient education and interactions
Give the patient a complete and written discharge plan
Employ teachback to ensure patients/families understand the care plan, information and explanations given and that their questions are answered
Provide culturally and linguistically appropriate care
Ensure continuity in care in order to build trust
Use a shared decision making approach
Ensure enough time is available for consultation
Discuss with the patient any tests or studies that have been completed and who will be responsible for following up the results
Confirm the medication plan with the patient
Ensure provider contact and follow-up information is provided to the patient
Review with the patient appropriate steps of what to do if a problem arises

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