What are the best practices for creating a comprehensive discharge plan?

Effective discharge planning in therapy hinges on collaboration, clear goals, a defined timeline, and client involvement. Collaboration empowers clients, considering all aspects of their well-being for a smoother transition. Define specific, measurable, attainable, relevant, and time-bound (SMART) treatment goals. Clear goals provide direction and track progress, ensuring a manageable transition. Establish an organized timeline with milestones and regular reviews. This proactive approach allows adjustments to align with evolving client needs. Encourage active client participation, fostering responsibility and self-efficacy. This commitment equips clients with the skills and knowledge for a successful transition.

A family meeting can be helpful as well but it is always important to gain the patient's consent and trust prior to engaging their caregivers and developing a comprehensive plan. Never assume you know what the patient's wishes are. It can be quite a surprise sometimes to hear their self-determined goals.

Case managers need to find ways to privately pay for care at home. Does the patient have a long term care insurance policy? Are they able to access a reverse mortgage? Do they have cash on hand? Do they have a family/friend circle who will volunteer their time? Short term care insurance? Can family members send money? Waiver services? VA aid and attendance? Using whole life insurance cash value? Health Savings Account (HSA)? Annuity? convert a hybrid life insurance policy into a long term care benefit? pension? What other sources of private pay can you access if you're going to need to need extensive help at home? If a family member is willing to provide the care, will the patient match their salary?

According to Ember Gard, Director of Service Operations at Innovative Care Management, Inc, Discharge planning should always begin at admission to ensure the best possible outcomes for the member. Engaging the patient and their support system early on will help to ensure that everyone involved is knowledgeable and prepared post discharge, including them as part of the care team and goal discussions is imperative. Consult with the patient's insurance for network information or additional benefits they might have available from their plan. Detailed information about a patient's home environment and strong consideration for SDoH is also key to setting people up for success outside the hospital setting.

I agree with Mary Ryan's view. I would like to add to start the approach as early as possible to avoid lengthy hospital stays when a patient is medically fit. the patient's voice is important in the whole process. We can not presume that family support is what the patient wants or the other way around. Family history might be a vital reason why certain ideas will fail and ultimately we want the patient to stay out of hospital.

Sadly Discharge planners do not refer to Care Managers We are the ones who find and assist and monitor with things like in home care. Advise Re reverse mortgages find solutions to provide the necessary engagement and ways to have enjoyable activities and or day care. Better nutrition, medication management and fall prevention safety in the home. We save families money and provide guidance and peace of mind

I would suggest to always include the true "key players" that are part of their daily activities. Not just the perspective of an OT or Physician for example but the PSW or caregiver who actually spends the bulk of their time with the patient can offer incredibly helpful insight.

It is helpful to include providers that continue the care following discharge, to ensure a smooth transition after discharge. This may require a shift towards a broader perspective on the multidisciplinary team. This can include a phone call to the primary care provider or some helpful suggestions in the management plan following discharge. In general, providing opportunities for communication between providers in different settings benefits safe continuation of care.

I suggest utilizing technology and keeping everyone in the loop from the consents and the people directly involved in managing the immediate needs to the team on an ongoing basis. We utilize RPM and CCM apps.

The "team" must also include the patient's funding source! The last sentence of this existing draft makes it look like the insurance coverage is a barrier/challenge - that is INCORRECT. Insurance should be an ALLIE.

Providing a clearly organized care plan is great. But as we know, when under stress adults do not absorb all of the information given to them. So it's important to provide follow up to confirm that they do in fact understand and answer questions they may have thought of after the fact.

Providing information and eduction about discharge should start at an early stage, outlining the role of hospital teams and the role of primary care teams in the continuation of care following discharge. It helps to reduce patient anxiety if they know that their providers communicate with each other and provide a timely clinical handover during transfer of care back to the community.

I agree, however the situation is often quite different when the patient reaches home, and are away from the hospital support. Community support is very necessary to maintain the education and identity any new challenges which may occur, for example worsening arthritis may reduce patients ability to use their inhalers. Public health could identify this early on and provide further resources/equipment needed. This would help prevent readmission to hospital at a later date.

In our context here in Cameroon, education is delivered at discharge but is lacking as HIV literacy is challenged by denial. It has become a necessity for our case workers to visit patients at home and to observe drug administration which is where the challenges remain. How do you access their home at 7pm when the child is supposed to take his medicine?

I greatly dislike the word EDUCATE in this draft. It's too paternalistic and does not recognize autonomy and existing knowledge levels.

Again, important to engage the key players and offer all options even if you think they may decline. Sometimes they need time to process the information and make an informed decision before you go to great lengths to arrange the actual care/services.

Timely communication (within 24 hours) with clinicians continuing care in the community reduces complications and re-presentations to hospital. A mutually agreed minimum set of data is important as part of the clinical handover. The management plan can include steps to take in case of certain situations to empower community providers and patients. It is helpful if contact details of the hospital team are provided so advice can be sought when needed.

A referral to a non medical home care company has to be a win win situation. As a case manager, you will need to make sure that the patient is able to pay for services and is willing to adhere to the discharge plan. The case manager will also have to consider that the company will be scrambling to find and pay a caregiver on a short notice then fill the need one week at a time. Sometimes it is a logistical nightmare for the company. You may celebrate that the patient is discharged from the hospital but then you get a call from the company that the patient will not let the caregivers in their house and not returning your calls. Did you collect three back up contacts to follow up the patient?

how about communicating with the insurance? too many times providers at the bedside ignore the entity responsible for paying the bills and THAT causes problems for patients

Evaluate and inquire of patient,family and caregivers for any barriers to carrying out the discharge and post treatment plan such as dietary needs, transportation to follow up appointments or other follow up disciplines. The assess the ability to obtain new medications and understand medication schedules and have the ability to read the labels on medication are important. Also patient and caregivers should be aware of medications side effect or other symptoms of condition that should be reported to the physician. These can help reduced re-admissions.

Yes and depending on their own personal journey another check in May be really helpful. Not everyone is comfortable with in person assessment so perhaps a phone or written check in is best

First check with the client/and or family if they need anything by reviewing goals. Then check with your supervisor. Then check with the team of support to review goals or concerns I.e. doctors, psychiatrist, Physio therapist, etc.

It is useful to regularly audit the clinical handover procedure for transfer of care back to the community. E.g.: In what percentage of discharges in the inpatient and outpatient setting is a discharge summary created and within what time frame? Does the document contain the minimum agreed data set needed for safe continuation of care in the community? This information can be used for monitoring, benchmarking and quality improvement purposes.

It's important to be patient and keep trying of the plan fails. I've had clients that I went to great lengths to create elaborate care plans only to have them refuse and then change their mind. They have the right to do this and it's important to be kind and respectful.

the words "patient centered" should be in this article. As should social determinants of health be addressed in this article. Be careful to maintain a tone of collaboration with ALL entities involved in not only providing hands on care to the patient, but paying for care being rendered to the patient. Also, don't ignore the fact that some patients have significant financial resources and may have the ability and desire to pay for care or services outside of "insurance". And, that lots of "insurance alternatives" such as cost-sharing programs exist as well.

I work remotely, I have found that most home health companies only want Medicare patients. I personally cannot believe that people are discharged without a company clearly being on board. Having to find one for patients after the fact is near impossible being from a self funded TPA. Be sure one is in place prior to discharge for the sake of the patient’s safety.