Maintaining patient health after a hospital stay...
RARE - Reducing Avoidable Readmissions Effectively

Comprehensive Discharge Planning

A comprehensive discharge planning process is one of five key areas known to reduce avoidable readmissions. Hospitals working on this topic will focus on ensuring that all of a patient's needs are considered and included in a comprehensive discharge plan with input from the patient and family. Interventions may consist of written, visual or recorded discharge plans that include and consider follow-up appointments, medications, nutritional needs, family support, transportation, health literacy, knowing whom to call, social problems, and red flags.

Comprehensive Discharge Planning - Tools and Resources >

Typical Transition Failures

Discharge Planning Process

  • Failure to actively include the patient and family caregivers in identifying needs and resources, and planning for the discharge
  • Lack of explicit roles and responsibilities identified for care providers
  • Lack of understanding of the patient's physical and cognitive functional health status
  • Too little time to create a complete discharge plan
  • Discharge planned when optimal staffing is not available or relegated to the least experienced member of the care team
  • Unrealistic optimism of patient and family to manage at home
  • Failure to recognize worsening clinical status in the hospital

Discharge Plan Content

  • Written discharge instructions that are confusing, contradictory to other instructions, or not tailored to a patient's level of health literacy or current health status
  • Lack of an emergency plan, including telephone number the patient should call first
  • No advance directive or planning beyond do not resuscitate status
  • Outdated medication plans, or plan not reconciled with medications that the patient has at home
  • Information that helps patient/family coordinate needed services and support incomplete or missing.

Care Coordination for Discharge

  • Lack of coordination and information sharing between the facility and community care providers (including primary care physicians)
  • Multiple care providers; patient believes someone is in charge
  • Availability and accessibility of case managers and social work support
  • Patient returns home without essential equipment (scale, supplemental oxygen)

Health Literacy/Communication

  • Patient/family education occur only during and at time of discharge
  • Patient/family intimidated to ask clarifying questions or for additional instruction
  • Patient/family education does not meet their level of health literacy
  • Too little time set aside to teach patients about their discharge plans
  • Provider contact information is not provided to the patient
  • Patient is not provided with a comprehensive discharge plan that they can understand and utilize to follow through with discharge instructions.

Best Practices/Strategies for Improvement

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
  • Ensure that 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)
  • Initiate discussions for advanced directives and advance care planning as appropriate to patient needs and condition.

Discharge Planning Content/Format

A written discharge plan includes the following:

  • Reason for hospitalization, including information on disease/condition
  • Medications to be taken post discharge, including, as appropriate, resumption of pre-admission medications.
    • Purpose of medication
    • Dosage of medication
    • When to take medication
    • How to take medication
    • How to obtain medication
  • Self-care activities such as diet, activity level or limitations, weight monitoring
  • Identify DME/supplies that patient will need for care
    • Purpose of DME/supplies
    • Where to obtain DME/supplies
  • Symptom recognition and management – what to do if patient has a question, a problem arises or condition changes, including a list of symptoms that indicate a health care provider should be notified
    • Who to contact
    • How to contact
    • Emergency contact
  • Coordination and planning for follow-up appointments
    • Appointment should be made by the hospital prior to discharge and should be within a specified number of days of discharge (based on patient's condition).
  • Coordination for follow up of test and studies for which confirmed results are not available at the time of discharge.
  • 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
  • Use 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 upon Discharge

  • 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
  • Ensure patient either has available, or understands how to access, medications on discharge
  • Ensure patient either has available, or understands how to access, essential equipment (DME) on discharge.
  • Ensure patient has adequate transportation for follow-up appointments

Health Literacy/Patient-provider Communication

  • Educate the patient and family about diagnosis throughout the care continuum
  • Embed health literacy principles into all patient education and interactions
  • Employ the teach-back method 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
  • Review with the patient appropriate steps of what to do if a problem arises
Patients and family members
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RARE is a campaign lead by the Institute for Clinical Systems Improvement, the Minnesota Hospital Association, and Stratis Health, which represents Lake Superior Quality Innovation Network in Minnesota.