The key components of a successful discharge care plan are to ensure a smooth and safe transition for patients from a care setting to their next setting. A well-executed discharge planning process, without avoidable complications, maximizes each resident’s potential to improve, to the extent possible, based on his or her clinical condition. It is also important that the interdisciplinary team and primary physician are all a part of the planning for a safe discharge.
The discharge plan is part of the comprehensive care plan and must be developed by the interdisciplinary team on admission and involve direct communication with the resident and if applicable the resident representative. The discharge plan should also address the residents’ goals for care and treatment preferences and should be regularly re-evaluated and updated.
Essential Elements
1. Patient assessment – Ensure that a comprehensive evaluation of the resident’s medical, psychological and social needs and determinants of health assessments are completed upon admission.
2. Care Coordination – Ensure that there is collaboration among the health providers, the resident and their family/representatives. This may include the need to do an onsite visit to the residents prior assisted living setting and/or a home visit by therapy to identify further needs or housing adaptations. Ensure you are communicating with the leaders at the assisted living or home care agency to ensure that there are services in place to safely care for the resident.
3. Follow Up Care – Help your residents by assisting with scheduling follow-up appointments with healthcare providers and arranging necessary home health services. It’s important to understand the resident’s baseline prior to hospitalization and/or admission to the facility. This helps to determine goals set by the therapy teams along with a tentative timeline for a discharge date.
4. Patient and Caregiver Education – Provide resources for community services, information on managing the patient’s condition, including diet and recommended exercises upon discharge. The registered dietitian may assist with diet and meal planning and therapy will include exercise education.
• Examples of Education in LTC – may include newly diagnosed diabetics with blood glucose testing, s/sx of hypo/hyperglycemia, Coumadin use, blood thinner injections, nebulizer, CPAP, wound dressing, IV therapy and medication management. It is important to identify upon admission what the resident/family may need education on and then ensure that this is discussed with the IDT and becomes a part of the discharge plan.
5. Equipment and Supplies – Ensuring the patient has access to necessary medical equipment and supplies.
• Examples; ordering a w/c, walker if needed (therapy often assists with this for Med A and Managed care). Oxygen in the home, wound management supplies or any of the equipment needed listed under education that may be applicable.
6. Support Services – Connecting the patient with community resources and support groups.
7. Documentation – Creating a written discharge plan that outlines all aspects of the patient’s care and follow-up instructions. A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment.
8. F628 Discharge Summary – Transfer and Discharge Regulations:
• Recapitulation of stay should include the following items:
> Diagnosis
> Course of illness including the treatment and therapy that the resident received during the care center stay
> Pertinent laboratory and radiology tests and results
> Pertinent consultations along with any findings and recommendations
• Medication Reconciliation:
> Medication Reconciliation of all pre-discharge medications and post-discharge medications this includes any over the counter medications.
> The post discharge plan of care should include:
a) Where the individual plans to reside
b) Any arrangements for follow-up care
c) Any post-discharge medical and non-medical services
Kris Ross, RN
Director of Clinical Services
For more information contact
consult@srcaresolutions.net
