When should the nurse initiate discharge planning?

17 January, 2013 By NT Contributor

Effective discharge planning is crucial to care continuity. This review gives an introduction to, and taster of, our newly launched Nursing Times Learning unit on discharge planning

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Education is essential to help patients take better care of themselves at home and reduce readmission rates said Streelman.

“Educating patients is the responsibility of the frontline nurse,” she said. “At Rush we use a variety of methods such as teach back, which requires patients and families to teach back to their nurse and tell him or her what they just learned, including a return demonstration of any hands-on skills that were taught. We also use approved videos with education modules accessible on TV for patients, their families and significant others, to view in their room during the patient’s admission.” The method is not a “one and done” process, either. “Teach back is an effective strategy for patients and is conducted several times with patients and their families throughout their stay, and at discharge, at Vanderbilt,” said Mays. How to draw up and inject insulin and inject Lovenox at home, are two examples of self-care skills patients may need to learn, she said. Streelman said another patient education method used at Rush are handouts with color coded zones for five of the major diagnosed conditions — CHF, renal disease, diabetes, COPD and myocardial infarctions. 

The handouts show four color zones: blue for everyday tasks patients need to do to monitor their condition; green, which indicates all is clear by listing the absence of specific symptoms — indicating their condition is under control; yellow, which signifies the patient is entering a caution/warning zone if specific symptoms are present and a call to their home health nurse or doctor for guidance is warranted; and red, which describes symptoms for their condition that are emergent and may need immediate medical attention via either a trip to the ED or by calling 911 for help. Vanderbilt also has a program called “meds-to-beds,” said Mays. If a hospitalized patient decides to obtain their discharge medications from the hospital’s pharmacy, instead of one outside the hospital, the medications are brought to the patient’s room by a pharmacy staff member and dosing instructions are given to the patient, she said.

“If patients have any barriers to getting their meds once they’re home, such as not having transportation to get to a pharmacy, this eliminates that barrier,” Mays said. “Plus, medication instructions from pharmacy staff helps to reinforce what the bedside nurse teaches during their admission, or I as a PFN gives to patients with their discharge instructions.” Follow up phone calls to patients within 48 hours of their discharge is another part of the discharge process, said Kimberly Linville, MSN, RN, nurse manager, 8 North Inpatient Medicine at Vanderbilt University Medical Center.

“Calling patients after their discharge helps to identify any gaps that may have occurred during the discharge process,” she said. “We work to resolve those gaps and also give feedback to the unit about any gaps regarding discharge. This helps to reduce readmissions.”

Once you leave hospital, it is important you continue to get the right healthcare and support from the right people. Discharge planning aims to make sure this happens. It is the link between the treatment you had in hospital and the care you will need in the community once discharged.

What is hospital discharge planning?

Discharge planning is the development of a personalised plan to ensure the smooth transition of a patient from a health organisation such as a hospital to wherever the patient is going next — it might be home, residential care, respite care, palliative care or somewhere else.

Good discharge planning can avoid complications after discharge from hospital, avoid errors with medications and may help prevent a person from being readmitted to hospital later on.

Who is involved in hospital discharge planning?

Discharge planning should involve the patient, carer, family and any staff involved in the patient’s care. Usually there will be one person, such as a discharge planner, who coordinates the process.

What is included in hospital discharge planning?

Discharge planning involves taking into account things like:

• follow-up tests and appointments
• whether you live alone
• whether someone can help you when you go home
• your mobility
• equipment needed for your recovery
• wound care, if needed
• medicines, especially if you need multiple medications
• dietary needs
• rehabilitation
• whether there will be any restrictions on you once discharged, for example driving or lifting

Discharge planning should ensure that all the services you need to support you once you leave hospital are in place.

This might include things like community support with medications, dressings, food or cleaning. It might include aids and appliances to help you stay in your own home, independently.

In some cases, it is simple. For example, you might be expected to leave hospital in 2 days with certain medications, and you might be told to see your GP 2 days after you get home.

But if you have a chronic disease or need plenty of ongoing care, it could be more complex. It might involve you, your GP, other healthcare professionals, family members and carers.

All of these people should have a copy of the discharge plan, so that everyone knows what they need to do to ensure that you have continuing care.

Where appropriate, other people or organisations should have a copy too. These could include a residential care facility, rehabilitation services or community services.

When is hospital discharge planning done?

Ideally, discharge planning starts as soon as you are admitted to hospital. And ideally, it also involves you and your family, as well as hospital staff. If you are going in for elective surgery, the discharge planning may occur before you go into hospital — so appropriate care can be organised in advance for when you get out.

A discharge summary is one part of a discharge plan. It is a document prepared while you are in hospital, usually by your hospital doctor. It is generally an electronic document, known as an electronic discharge summary (eDS).

The hospital should send it to other healthcare professionals involved in your care, such as your GP or sometimes a pharmacist or carer.

It is important your GP gets a copy of this document so that they know why you were admitted to hospital, what care you received and how to continue to care for you.

A copy of the electronic discharge summary will also be added to your ‘my Health Record, unless you have opted out of having one. You may also be given a paper copy of the summary when you leave hospital.

The discharge summary will explain:

• why you were admitted to hospital
• the main diagnosis
• which tests were performed
• what care you received
• which medications you are taking on discharge from hospital, and possibly which medications you have taken in the past
• which other medications you have taken in the past
• which medical or surgical procedures were performed
• whether you had any allergies or bad reactions
• a clinical summary of your situation now and follow-up actions
• which future services have been arranged, such as community services
• any follow-up appointments that have been made

Tips for a safe hospital discharge

Here are some questions you could ask yourself before you are discharged from hospital:

• Do I understand what happened in hospital?
• Do I understand which treatment I need now — and in the future?
• Do I know which medications to take and when? Do I have enough of those medications until I can see my GP?
• Do I need to make any dietary changes? Will I be able to shop for food and manage to feed myself?
• Do I know when my follow-up appointments are?
• Has my GP been informed of my admission and of my discharge plan?
• Do I need care from family members? If so, has there been a family meeting? Does everyone understand their roles and responsibilities?
• Do I have transport arranged?
• Am I allowed to drive once discharged?
• Do I have an estimate of recovery time or time for any wounds to heal?
• Are there any concerns or questions I should raise before I am discharged from hospital?

If you can’t answer those questions, please ask your hospital doctors and nurses for more information. It is their responsibility to make sure you have it all. If you still don’t have everything you need, ask for a nursing supervisor.

Find a healthcare service with healthdirect’s Service Finder tool or call 1800 022 222 (known as NURSE-ON-CALL in Victoria) for 24-hour health advice and information.

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Last reviewed: March 2022