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 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 a discharge entails and outline five best practices to optimize the safety and efficiency of your process.
What Is a Discharge Plan?
A discharge plan helps patients have smoother transitions between different 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.
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.
How Is a Discharge Plan Documented?
There’s no universal template used for documenting discharge planning. Examples of what sections and information might be included in a discharge summary are provided below. However, it’s important to use a documentation format that works best for your staff, patients, and EHR system. This could be as simple as a free text box, or as structured as a checklist.
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| Patient Details | Essential components of a patient’s medical history, such as their name, date of birth, age, sex, contact information, and address |
| Problems and Diagnoses | All of the principal and secondary diagnoses, complications, procedures, and past medical histories most relevant to the treatment provided at the hospital |
| Presentation Details | Basic care information such as the patient’s admission date, expected discharge date, type of episode, clinical unit, and anticipated discharge destination |
| Recommendations for Continuity of Care | Recommended actions that should be taken to coordinate discharge plans and the staff members responsible for initiating these actions |
| Medications | Medications that a patient has been on in the hospital and any medications they will continue to take at home |
| Patient Needs and Precautions | Any safety risks or medical alerts, such as impaired mobility and hearing, and individual needs like language interpreters |
| Follow-Up Appointments | Referrals and appointments, booking status, location, and contact details of providers |
Why Is Discharge Planning Important?
A sound discharge 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 a Discharge 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 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 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 appropriate post-discharge services.
Once a physician medically clears a patient for discharge, they must communicate and coordinate 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.
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 your checklist can be accessed by your staff in a central location, such as your electronic health record (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.
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