Hospital Discharge Planning: 5 Best Practices

Discharge planning is an essential part of delivering quality care, involving everything that goes into transitioning a patient between different care settings. Without a personalized or medically appropriate discharge (d/c) plan, patients are at risk of falling through the cracks of the healthcare system and facing preventable readmissions.

Since there’s no standardized process for discharging patients, it’s important for facility leaders to implement protocols that reflect evidence-based practices. In this article, we’ll provide an overview of what d/c planning entails, with a downloadable example discharge plan template, and five best practices for optimizing the safety and efficiency of your process.

What Is Discharge Planning’s Primary Purpose?

Planning for patient discharges creates smoother transitions between alternate levels of care, such as from the hospital to home — or to other care settings like rehab centers and long-term care facilities. In order to create a plan that’s individualized to each patient, providers must conduct comprehensive assessments and coordinate services with an interdisciplinary team.

What Is In a Discharge Plan?

A discharge plan covers all of the psychosocial, medical, and personal needs that should be addressed in a patient’s next phase of care. While the exact components of a patient’s plan can vary based on their individual needs, it should typically outline:

• The location where a patient is being discharged/transferred to.
• The types of services and care patients will need after discharge.
• What the patient and family should do at home to support recovery.
• Medication prescriptions and instructions on usage.
• Arrangements for any medical equipment or supplies necessary for recovery.
• Community resources that can support the patient’s psychosocial needs.
• Resources that can help the patient pay for their care.

What Is a Discharge Planner’s Process?

Although any caregiver can plan a discharge, in hospitals, it’s typically the job of case managers. Their job starts by assessing a patient’s likely post-discharge care needs, then beginning the coordinating efforts to assemble those requirements so they’re available as soon as the patient’s ready to d/c.

Even for these dedicated professionals, there’s no universal template used to guide discharge planning. Examples of what sections and information might be included in a case manager’s discharge summary are provided below. However, it’s important to use a documentation format that works best for your staff, patients, and electronic health record (EHR) system. This could be as simple as a free text box, or as structured as a checklist (like in the printable d/c planning template provided above).

Why Is D/C Planning Important?

A sound discharge care plan ensures that patients are fully supported in their recovery once they leave the hospital. This promotes continuity of care and reduces the risk of preventable complications, such as hospital readmissions and worsened health outcomes. Actively involving patients and family members in their planning is also an important way to engage them in their own care. This can improve patient satisfaction and ensure that they’re equipped to care for themselves outside of the hospital.

5 Best Practices for Creating an Effective Discharge Care Plan

Now that we’ve gone over what goes into planning a discharge, here are five best practices to help you improve your facility’s discharge protocols.

1. Start D/C Planning as Early as Possible

While this may sound counterintuitive, discharge plans should start being made as soon as a patient is admitted to the hospital. As your team conducts intake assessments and reviews medical histories, they should be estimating potential discharge dates and noting any care/services that the patient may need. This ensures that all referrals and services can be secured in a timely manner.

2. Define the Responsibilities of Each Hospital Team Member

Several members of the care team contribute to discharge planning. Nursing professionals are often responsible for delivering and documenting discharge education, while social workers and case managers help identify and coordinate appropriate post-discharge services.

Once a physician medically clears a patient for discharge, they must communicate the patient’s plan with the rest of the care team. As a facility leader, it’s important to clearly outline who’s responsible for what in your discharge protocols. In doing so, you can ensure that essential tasks aren’t overlooked and there’s no redundancy in documentation.

3. Actively Involve Patients and Families in the Process

Beyond coordination among the care team, it’s vital to involve the patient and their family in all phases of the planning process. At baseline, your care team should be assessing the patient’s needs regarding:

• Barriers to at-home care (e.g., lack of social network).
• Specialized services (e.g., mental health care, transportation).
• Personal preferences (e.g., service costs, religious/cultural considerations).

Additionally, patient education should be conducted throughout their entire stay at the hospital. This ensures that patients (or their family/caregivers) can independently use any equipment or medications that they’ll be expected to continue at home. Once it’s time for discharge, additional education and written instructions should be provided to confirm the patient’s understanding of all the measures needed to support their recovery.

4. Adopt a Standardized Discharge Planning Checklist

While there’s no universal discharge checklist that applies to all settings, it’s important to standardize the discharge planning steps required at your facility. Creating a checklist for your staff will ensure that no key aspects of the process are missed.

Beyond our provided checklist-style template, the Agency for Healthcare Research and Quality (AHRQ) provides an evidence-based discharge toolkit that your facility can use (making adaptations as needed). Make sure that whatever form you use can be accessed by your staff in a central location, such as your EHR system, and train your staff on where and how to document discharge notes.

5. Coordinate Follow-Up Appointments

It’s also important to schedule all follow-up appointments that are necessary to monitor the patient’s recovery process. This should be done at least a day in advance of discharge. These appointments may include but are not limited to:

• Visits with a primary care provider.
• Dates for lab or diagnostic tests.
• Medical equipment delivery.
• Dates that home care staff should visit.
• Visits with any medical specialists.

Patients should also be consulted about their preferences in providers and any cost coverage considerations. This will promote compliance and help prevent potential complications that arise from missed appointments.

Get More Tips on How to Deliver Quality Care

Now that you’ve seen several examples of discharge planning — with templates to boot — you may be ready to look at other crucial aspects of the patient care journey. Use our expert-backed facility guides and tips for some of the latest insights on effective healthcare workflows and clinical throughput.