“The Importance of a Discharge Planning Meeting”
- 20% of Medicare patients discharged from the hospital are readmitted within 30 days
- 33% of Medicare patients are readmitted to the hospital within 90 days
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Research shows that 20% to 30% of adverse events following discharge that lead to readmission are preventable, and another 30% of these events could at least be minimized.
Some of the events that are attributed to patient readmissions include:
- Fragmented system of care
- Lack of patient understanding about their diagnosis, care plan, or follow up instructions
- Failure to fill new prescriptions
- Confusion about medications that were prescribed while in the hospital
- Lack of understanding whether to continue medications prescribed before the hospital visit
- Absence of a discharge plan that addresses patient issues and provides needed services
- Poor coordination of care between hospital staff and primary care physician
- Uncertainty about which doctor to see for follow up (primary care physician or specialist)
- Inability of the patient to fill prescriptions, schedule appointments or arrange for transportation doctors
Source: The Revolving Door, Feb 2013
What is Discharge Planning?
According to Medicare, discharge planning is “A process used to decide what a patient needs for a smooth move from one level of care to another.”
The goal of discharge planning is to work with the patient and their family to create a plan that will identify the best level of care and services for a person after they leave the hospital, while reducing adverse events and preventable readmissions.
Keep in mind that a patient may have arrived at the hospital from home, an assisted living facility, short term rehabilitation, or a nursing home.
A Discharge Planning Meeting
The discharge planning process starts the first day the patient is in the hospital, and continues until the patient is officially discharged. In my work as a certified case manager with clients who are hospitalized, I always request a discharge planning meeting well in advance of the discharge date.
Participants in the meeting usually include the patient, family members, and members of the patient’s hospital care team. Depending on where the patient resided prior to admission, participants in this meeting may include the primary care physician, a representative from an assisted living facility, short term rehabilitation facility, or a nursing home; as well as any other people deemed appropriate.
Sample Questions for a Discharge Planning Meeting
This is a list of some questions that the patient and their family may find helpful to ask, when designing a plan for the next step after the patient leaves the hospital.
- What is the most appropriate post-hospital discharge destination for the patient based on their abilities and needs? (e.g. home with no assistance, home with assistance, a family member’s home, short term rehabilitation, assisted living facility, or nursing home)
- Is the patient at their pre-hospital level of functioning?
- Does the patient qualify for rehabilitation services in a facility or at home?
- Does the patient and/or family need to explore assisted living facilities or nursing homes?
- What does the patient prefer to do? Is this realistic?
- Does the patient have family who will help with care?
- Is the patient's residence compatible with their current issues and needs?
- Is home modification necessary? (e.g. ramp, grab bars, raised toilet seat)
- What services can the patient afford?
- Is there a need for additional patient education? (e.g. diabetes, colostomy, IV antibiotics, etc.)
- Is there any indication of abuse or neglect?
- What equipment and services are needed? (e.g. wheelchair, caregiver, transportation)
- What options best meets the patient’s needs and wishes?
This may all seem very overwhelming, but if taken step by step, this process will help improve the patient’s health, safety and quality of life.
If you feel that this is too much to handle on your own, you can seek help from a professional such as a certified case manager, physician, or nurse.
Our future articles will focus on a variety of health and mental topics, in an effort to help readers
become more knowledgeable and comfortable in their role as advocates, for themselves and their loved ones.
The Caregiver Resource Center
The Caregiver Resource Center assists seniors, people with special needs and their families in planning for and implementing ways to allow for the greatest degree of independence, safety and quality of life.
We are available 7 days a week by appointment, and 24/7 for emergencies. All of our services are individually designed to meet the unique needs of the client and their family.
For more information, or to request an initial consultation, please contact:
Linda Ziac, LPC, LADC, BCPC, CEAP, CCM, CDP
The Caregiver Resource Center
Greenwich, CT
203-861-9833
Disclaimer
The information in this article is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information is not intended to be patient education, does not create any patient provider relationship, and should not be used as a substitute for professional diagnosis and treatment.
Please consult your health care provider for an appointment, before making any healthcare decisions or for guidance about a specific medical condition.
To learn more about health and mental topics and to become a more educated self advocate, please subscribe to this blog or visit us at www.CaregiverResourceCenter.com
