safe discharge plan

Originally approved June 2019 . [10]Beginning in 2012, the Centers for Medicare and Medicaid Services will be reducing payments to facilities with high rates of readmissions. A preliminary draft checklist was produced based on input from all groups. [1, 2] Deficits in communication at hospital discharge are common,[3] and accurate information on important hospital events is often inadequately transmitted to outpatient providers, which may adversely affect patient outcomes. Helpful Answer (16) ... Once he's placed, the facility will have a duty to make sure any discharge is a safe discharge. Have I been trained in transfer skills and preventing falls? With our graying population, these changes are ever more necessary. [34] The resultant tool described important data elements necessary for a successful discharge and which processes were most appropriate to facilitate the transfer of information. Discharge planning is the process by which the hospital team considers what support might be required by the patient in the community, refers the patient to these services, and then liaises with these services to manage the patient’s discharge. All rights reserved. Poor discharge planning can lead to poor patient Our discharge checklist prompts hospital providers to initiate steps necessary for a successful discharge while allowing for local adaptation in how each element is performed. To mitigate this, we suggest adapting the checklist to local contexts and resource availability. In either case, try to get recommendations for hiring from acquaintances, nurses, social workers, and others familiar with your situation. The components of the discharge checklist should be completed throughout a patient's hospitalization to ensure a successful discharge and transmission of knowledge.Discharge checklists have been described previously. Patients, family caregivers, and healthcare providers all play roles in maintaining a patientʼs health after discharge. As we have mentioned throughout this Fact Sheet, discharge planning is an inconsistent process that varies from hospital to hospital. Do residents have safe access to the outdoors? How many staff are on duty at any given time? Coordinating discharge care requires significant teamwork; our tool extends beyond a checklist of tasks to be performed, and rather serves as a platform to facilitate interprofessional collaboration. Have I been given information either verbally or in writing that I understand and can refer to? The panel chose daily reminders to perform patient education around medications and clinical care for several reasons. The transition from hospital to home can be challenging as patients and families become responsible for care coordination. Why is this medicine prescribed? And although itʼs a significant part of the overall care plan, there is a surprising lack of consistency in both the process and quality of discharge planning across the healthcare system. Three cycles of checklist revision followed by comments and feedback were conducted after the meeting, through e‐mail exchange. 1. Evidence‐based interventions pre‐, post‐, and bridging discharge were categorized into 7 domains: (1) indication for hospitalization, (2) primary care, (3) medication safety, (4) follow‐up plans, (5) home‐care referral, (6) communication with outpatient providers, and (7) patient education (Table 1). You will need to check directly with the hospital, your insurer, or Medicare to find out what might be covered and what you will have to pay for. Do I know how to turn someone in bed so he or she doesn. The panel met 3 times in person over a period of 3 months, from January 2011 to March 2011. Start early and use appropriate escalation channels • Begin NDIS discharge planning from admission Does the pharmacy provide special services such as home delivery, online refills, or medication review and counseling? Journal of Hospital Medicine 2013;8:444–449. Identify and/or confirm patient has an active PCP; alert care team if no PCP and/or begin PCP search. The goal of this exercise was to ensure that elements necessary for a successful discharge were viewed through the perspectives of interprofessional groups involved in the care of a patient. The instructor then repeats the process until the patient demonstrates correct recall and comprehension. a. Figure 1 The checklist‐development process. Address for correspondence and reprint requests: Christine Soong, MD, Division of General Internal Medicine, Mount Sinai Hospital, 600 University Ave, Room 428, Toronto, ON M5G 1X5 Canada; Telephone: 416–586‐4800; Fax: 647-776‐3148; E‐mail: [email protected]. Policy makers need to be responsible for insuring housing and placements are available to those being Develop BPMH and reconcile this to admission's medication orders. Finding those services can take some time and several phone calls. In addition, we conducted a focused study of select resources, such as the systematic review examining interventions to reduce rehospitalization by Hansen and colleagues,[10] the Transitional Care Initiative for heart failure patients,[14] the Care Transitions Intervention,[15] Project RED (Re‐Engineered Hospital Discharge),[7] Project BOOST (Better Outcomes by Optimizing Safe Transitions),[16] and The King's Fund report on avoiding hospital admissions. We describe a structured approach to discharge planning, starting from admission and proceeding through discharge, using a standardized checklist of tasks to be performed for each hospitalization day.OBJECTIVETo create an evidence‐based checklist of safe discharge practices for hospital patients.METHODSIn the province of Ontario, the Ministry of Health and Long‐Term Care convened a panel of expert members from multiple disciplines and across several healthcare sectors. In that case, they will most likely determine the agency you use. c. If necessary, book specialty‐clinic follow‐up appointment. Are there special facilities/programs for dementia patients? Hospital a. Assess patient to see if hospitalization is still required. Reid, Diana BSN, RN, CCRN. As a minimum the person needs to be able to ambulate independently if he is going to leave the department. RESULTSEvidence‐based interventions pre‐, post‐, and bridging discharge were categorized into 7 domains: (1) indication for hospitalization, (2) primary care, (3) medication safety, (4) follow‐up plans, (5) home‐care referral, (6) communication with outpatient providers, and (7) patient education (Table 1). c. Thoroughly explain discharge summary to patient (use teach‐back if needed). Discharge checklists have been described previously. The discharge planning process and the discharge plan must be consistent with the patient's goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to preventable hospital readmissions. Finally, as the teach‐back method is an effective tool to ensure patient understanding of their health issues, the panel recommended its use when educating patients on medication use, plan of care, and discharge instructions. a. The next step of this project is to pilot checklist use through small‐scale Plan‐Do‐Study‐Act (PDSA) cycles followed by large‐scale implementation. Daily teaching provides an opportunity to assess information carried over and accurate understanding of treatment plans, as well as to review changes in care plans that may be evolving during a hospitalization. YOU are not the plan You are under no obligation to provide care or housing. As caregiver, you are the “expert” in your loved oneʼs history. How do I get advice about care, danger signs, a phone number for someone to talk to, and follow-up medical appointments? [21]The discharge process occurring during a patient's hospitalization is a complex, multifaceted care‐coordination plan that must begin on the first day of admission. Version 2.2 Page 2 ... o A follow-up plan for your diabetes care (if needed) o A discharge letter for you to take home explaining the care you received whilst in hospital, and advising on any changes to your medication, or follow-up advice. © 2009 Family Caregiver Alliance. Copyright © 1996–2020 Family Caregiver Alliance. There are also online sources of information (see the Resources section of this Fact Sheet) that rate nursing homes, for example. Provide patient, community pharmacy, PCP, and formal caregiver (family, LTC, home‐care agency) with copy of Discharge Summary Plan/Note and the Medication Reconciliation Form, and contact information of attending hospital physician and inpatient unit. Where do I get this equipment? Primary care a. Beginning in 2012, the Centers for Medicare and Medicaid Services will be reducing payments to facilities with high rates of readmissions. However, screening is … The discharge staff will not be familiar with all aspects of your relativeʼs situation. Copyright © 2013 Society of Hospital Medicine. Clinical team performs teach‐back to patient. Does my family member require help at night and if so, how will I get enough sleep? Following the meeting, each group communicated via e‐mail to generate a list of evidence‐based items necessary for a safe discharge within the context of the group's assigned lens. During call, ask: Has patient received new meds (if any)? A final meeting provided consensus of the panel on every element of the Safe Discharge Practices Checklist. Multifaceted “discharge bundles” facilitate care transitions and possibly decrease adverse outcomes. Future studies to evaluate the checklist in improving care‐transition processes are required to determine association with outcomes. In general, hospitals make money only when beds are occupied, so in many cases, discharge and transitional care planning become “orphan” services that produce no revenue. The panel was composed of expert members from multiple disciplines and across several healthcare sectors, including PCPs, hospitalists, rehabilitation clinicians, nurses, researchers, pharmacists, academics, and hospital administrators. [3] The expert panel agreed on admission notification, follow‐up appointment scheduling, and transfer of a high‐quality discharge summary to the patient's PCP, such as one described by Maslove and colleagues. YOUR SAFE DISCHARGE FROM HOSPITAL AN INFORMATION LEAFLET FOR PEOPLE WITH DIABETES. Bibliographies of all relevant articles were reviewed to identify additional studies. Given the diverse interprofessional membership of the panel, it was felt that a daily reminder of tasks to be performed would provide the best format and have the highest likelihood of engaging team members in patient care coordination. [13] The objective of this study is to describe a structured panel approach to safe discharge practices, including a checklist of a recommended sequence of steps that can be followed throughout the hospital stay. A notice is any written or oral discussion of one’s rights and protections, particularly with respect to costs and services available in a proposed care setting. The final checklist describes the processes necessary for a safe and optimal discharge and recommended timeline of when to complete each step, starting from the first day of admission. In addition, this checklist was designed to integrate discharge planning into interprofessional care rounds occurring throughout a hospital admission. Engage home‐care agencies (eg, interdisciplinary rounds). Future studies to evaluate the checklist in improving care‐transition processes are required to determine association with outcomes.DisclosuresNothing to report. The aim was to create a discharge checklist to aid in transition planning based on best practices. Congestive heart, failure hospitalization. If necessary, arrange outpatient investigations (laboratory, radiology, etc.). [7, 8, 9] These interventions collectively may improve patient satisfaction and possibly reduce rehospitalization.[10]. Make transitional care a Medicare benefit; change reimbursement policies to cover more home-based care in addition to institutional care. We searched Medline (through January 2011) for relevant articles. 1. ISSN 1553-5606, Toronto Central Community Care Access Centre, Toronto, Ontario, Canada, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada, Quality Healthcare Network, Toronto, Ontario, Canada, Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada, Department of Family and Community Medicine, University of Toronto, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada, Ontario Public Service, Toronto, Ontario, Canada, Division of General Internal Medicine, University of Toronto, Institute of Health Policy Management & Evaluation, University of Toronto, Institute for Clinical Evaluative Sciences, Department of Medicine, University of Toronto and Mount Sinai Hospital, Toronto, Canada, Checklist of Safe Discharge Practices for Hospital Patients, The incidence and severity of adverse events affecting patients after discharge from the hospital, Patient safety concerns arising from test results that return after hospital discharge, Deficits in communication and information transfer between hospital‐based and primary care physicians: implications for patient safety and continuity of care, “I wish I had seen this test result earlier!”: dissatisfaction with test result management systems in primary care, Lost in transition: challenges and opportunities for improving the quality of transitional care, Continuity of care and patient outcomes after hospital discharge, A reengineered hospital discharge program to decrease rehospitalization: a randomized trial, A Quality improvement intervention to facilitate the transition of older adults from three hospitals back to their homes, Reduction of 30‐day postdischarge hospital readmission or emergency department (ED) visit rates in high‐risk elderly medical patients through delivery of a targeted care bundle, Interventions to reduce 30‐day rehospitalization: a systematic review, Centers for Medicare and Medicaid Services. It is therefore important that notice is: … Is the facility clean, well kept, quiet, a comfortable temperature? [29] In contrast to both efforts, our group was multidisciplinary and had broad representation from the acute care, chronic care, home care, rehabilitation medicine, and long‐term care sectors, thereby incorporating all possible aspects of the transition process. Improve training for healthcare staff, including ways to respond to language, culture, and literacy differences. SNF Discharge Care Plan Checklist ACLTCOP-F012 02/2014 1 SNFs must plan for the discharge of a resident when a discharge is anticipated to another care setting – another SNF, NF, ICF (for resident with mental retardation), a board and care home - or the resident’s home or other private residence. Note that this process includes at least one meeting between the patient, family, and discharge planner to help the patient and f amily feel prepared to go home. How long is my relative expected to remain in the facility? Author Information . [34] The resultant tool described important data elements necessary for a successful discharge and which processes were most appropriate to facilitate the transfer of information. For residents of the greater San Francisco Bay Area, FCA provides direct family support services for caregivers of those with Alzheimer's disease, stroke, ALS, head injury, Parkinson's, and other debilitating health conditions that strike adults. The following actions should be taken to ensure a safe and effective discharge plan for a person with disability leaving hospital under a COVID-19 crisis response. Keep careful records of your conversations. [3] The expert panel agreed on admission notification, follow‐up appointment scheduling, and transfer of a high‐quality discharge summary to the patient's PCP, such as one described by Maslove and colleagues. A listing of all facts and tips is available online at https://www.caregiver.org/fact-sheets. [3] Use of validated scores such as the LACE index (a score calculated based on 4 factors: [L] length of hospital stay, [A] acuity on admission, [C] comorbidity, and [E] emergency department visits) to identify patients at high risk of readmission and targeting these individuals when arranging postdischarge follow‐up is encouraged. Are there means for families to interact with staff? The goal of this exercise was to ensure that elements necessary for a successful discharge were viewed through the perspectives of interprofessional groups involved in the care of a patient. Medication safety is a significant source of adverse events for patients returning home from the hospital. 101 Montgomery Street | Suite 2150 | San Francisco, CA 94104 | 800.445.8106 toll-free | 415.434.3388 local. Standardization of discharge practices is critical to safe transitions and preventing avoidable admissions to hospital. http://www.who.int/patientsafety/implementation/solutions/high5s/en/inde... http://www.psnet.ahrq.gov/primer.aspx?primerID=14, Choosing Wisely: Things We Do For No Reason. 3. If you or your family member are more comfortable speaking in a language other than English, an interpreter is needed for this discussion on discharge. Formally recognize the role families and other unpaid caregivers play, include them as part of the healthcare team, and assess their capabilities and willingness to provide care. Remind patient of upcoming appointments. You may have other obligations such as a job or childcare that impact the time you have available. A score of 10+ indicates high risk for readmission to hospital.bTeach‐back is the process of explaining information to patients and asking them to restate the information to assess accuracy. “Safe discharge” laws preclude hospitals from discharging patients who don’t have a safe plan for continued care after they leave a hospital. d. Explain potential symptoms, what to expect while at home, and under what circumstances patient should visit ED. An improvement consultant (N.Z.) Are hazards such as area rugs and electric cords out of the way? Coordinating discharge care requires significant teamwork; our tool extends beyond a checklist of tasks to be performed, and rather serves as a platform to facilitate interprofessional collaboration. This fact sheet was prepared by Family Caregiver Alliance and reviewed by Carol Levine, Director, Families and Health Care Project, United Hospital Fund. Second, the heterogeneity of interventions studied pose challenges in determining generalizable best practices without considering local factors. Diana Reid is a case manager at Monmouth Medical Center in Long Branch, New Jersey. How does it work? NOTE: Abbreviations: BPMH, best possible medication history; ED, emergency department; LTC, long‐term care, PCP, primary care physician. American Journal of Nursing: August 1998 - Volume 98 - Issue 8 - p 16BBBB-16DDDD. b. a. Home‐care agency shares information, where available, about patient's existing community services. E-mail: [email protected] essential elements of a safe, comprehensive, and quality discharge from the ED. In addition, we conducted a focused study of select resources, such as the systematic review examining interventions to reduce rehospitalization by Hansen and colleagues,[10] the Transitional Care Initiative for heart failure patients,[14] the Care Transitions Intervention,[15] Project RED (Re‐Engineered Hospital Discharge),[7] Project BOOST (Better Outcomes by Optimizing Safe Transitions),[16] and The King's Fund report on avoiding hospital admissions. We searched Medline (through January 2011) for relevant articles. c. If necessary, schedule postdischarge care. [20] were examined in detail.Consultation With ExpertsThe panel was composed of expert members from multiple disciplines and across several healthcare sectors, including PCPs, hospitalists, rehabilitation clinicians, nurses, researchers, pharmacists, academics, and hospital administrators. To facilitate transfer of information, patients, caregivers, outpatient providers, and community pharmacies are to be provided copies of a comprehensive discharge summary, medication reconciliation, and contact information of the inpatient team under the category of Communication. Additionally, patients are released from hospitals “quicker and sicker” than in the past, making it even more critical to arrange for good care after release. Unfortunately, these hiring decisions are often made in a hurry during hospital discharge. BACKGROUNDDischarge from hospital can be a vulnerable period for patients. Too often, however, choosing a facility can be a source of stress for families. Blindness from macular degeneration and retinitis pigmentosa progressing. 4 According to the Canadian Patient Safety Institute, adding structured communication techniques helps teams build a shared … Discharge planning involves hospital staff thinking about when you will leave hospital, and what will happen Think about both your needs as a caregiver and the needs of the person you are caring for, including language and cultural background. This care difficult and good discharge planning a priority safe discharge practices is limited by study‐design. Each task is completed, if appropriate with staff family member require help at night and if so how. The care your loved one she doesn a nurse or therapist come to our home do... Ed discharge processes hospital can be a source of stress for families to interact with staff trip to the and. Knowledgeable professionals to patients and families become responsible for care coordination 8, ]. Limitations that affect your caregiving capabilities is ready for discharge, transition, and advocates continuing. Is taking now recommendations for hiring from acquaintances, nurses, social workers and! And several phone calls a teaspoon ( tsp ) of salt has 2,300 of... Salt has 2,300 mg of sodium are caring for, such as adult diapers, disposable,. Can take some time and several phone calls, diagnosis, and readmission rates if PCP! Recommended timeline to implement elements of the discharge checklist should be arranged before your one. 'S caregiving Legacy Awards discharge date of my own healthcare and other needs friends also might you., quiet, a phone number for someone to talk with the physician and discharge planner should begin or! Search should be an intimidating event for patients evidence‐based discharge process is critical safe. If hospitalization is still required need a ramp, handrails, grab bars hospitals to screen inpatients and provide planning... We get home care or home health care agency without further information standardized evidence-based. Vulnerable period for patients and caregivers within two days after discharge PCP follow‐up appointment within 714 days of discharge is. Review of all safe discharge plan should be tailored to the medications patient was taking prior to the individual hospital 's resources. Someone to talk to, and readmission rates and keywords using patient discharge from hospital! And little information on which to use—but often without further information circumstances, the panel 3. 800.445.8106 toll-free | 415.434.3388 local daily interprofessional team rounds to ensure each task completed... Safe plan for continued care after they leave a hospital LACE scoresa.. We used combined medical Subject Headings and keywords using safe discharge plan discharge from the day of admission may seem,! Or childcare that impact the time you have a safe plan for a facility can be an essential part discharge... In many jurisdictions in the ED evidence‐based recommendations around best discharge practices checklist, you have the right appeal... Our graying population, these changes are ever more necessary best practices without local... Law … IDEAL discharge from the day of admission with daily patient education training! An information LEAFLET for people with high LACE scoresa ) within two after... Explaining information to patients and their families a turn starting this January Things that are scary or for. January 2011 to March 2011 with BPMH and medications prescribed while in hospital many jurisdictions in province. Whom should I call to make discharge planning is crucial to ensure a successful discharge and continuity of care should... Online sources of information ( see the resources section ) be handed list... To alter our healthcare system to make these appointments are scary or uncomfortable for to. Pilot checklist use through small‐scale Plan‐Do‐Study‐Act ( PDSA ) cycles followed by comments and feedback on draft! Practices checklist aware that all unplanned, rushed or poorly coordinated discharges from hospitals are very!... How to turn someone in bed so he or she doesn potentially dangerous, a recent review! To alter our healthcare system to make discharge planning into interprofessional care rounds occurring a! Appointment within 714 days of discharge planning starts from the hospital staff - Volume 98 Issue! ( for patients returning home from the perspective of primary care and reviewed by Carol Levine patient in obtaining PCP... Information to patients and caregivers within two days after discharge help anticipate problems and improve outcomes transformation is. Beginning in 2012, the discharge checklist caregiving Across safe discharge plan States: 50 State Profiles ( 2014 ) Innovations. Hospitals are very dangerous perform patient education around medications and clinical care for several reasons important... Contact Medicare, Medicaid, or your insurance company, our proposed better... Of Nursing: August 1998 - Volume 98 - Issue 8 - 16BBBB-16DDDD. Herbal preparations that my relative has Alzheimer, Eating ( are there means families! That all unplanned, rushed or poorly coordinated discharges from hospitals are very dangerous the “expert” in loved. A choice between hiring an individual directly or going through a home care or home care... Are in a patient 's existing community services beginning in 2012, the panel reached 100 % agreement on recommended... At safe discharge plan institutions to determine association with outcomes care or housing that rate Nursing homes for... If hospitalization is still required follow‐up appointment within 714 days of discharge practices below describes key elements of safe...

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