How can you train physicians to properly plan patient discharge?

1 Identify the goals and needs of the patient

The first step in planning patient discharge is to identify the goals and needs of the patient, such as their diagnosis, prognosis, preferences, social support, and functional status. You can use tools such as the Patient-Centered Discharge Planning Checklist or the INTERACT Quality Improvement Tool to help you gather this information. You should also involve the patient and their family or caregivers in the discussion, and address any questions or concerns they may have.

2 Coordinate with the interdisciplinary team

The next step is to coordinate with the interdisciplinary team, such as nurses, pharmacists, social workers, case managers, and home health agencies, to ensure a smooth transition of care. You should communicate clearly and regularly with the team members, and assign roles and responsibilities for each aspect of the discharge plan. You should also use standardized protocols and checklists, such as the Project RED or the Project BOOST, to facilitate the coordination and documentation of the discharge process.

3 Educate the patient and their family or caregivers

The third step is to educate the patient and their family or caregivers about the discharge plan, including the medications, follow-up appointments, self-care instructions, warning signs, and emergency contacts. You should use simple and clear language, and provide written materials, such as discharge summaries, medication lists, or patient education handouts. You should also use teach-back or show-me methods to verify the patient's understanding and adherence, and ask for feedback and confirmation.

4 Arrange for appropriate post-discharge services and support

The fourth step is to arrange for appropriate post-discharge services and support, such as home health care, rehabilitation, palliative care, or hospice care, depending on the patient's needs and preferences. You should consult with the patient and their family or caregivers, and the interdisciplinary team, to determine the best options and referrals. You should also ensure that the patient has access to the necessary equipment, supplies, and transportation for their post-discharge care.

5 Communicate with the primary care provider and other specialists

The fifth step is to communicate with the primary care provider and other specialists who will be involved in the patient's ongoing care, such as the patient's medical home or chronic care management program. You should send a timely and comprehensive discharge summary, including the diagnosis, treatment, medications, follow-up plan, and any pending tests or issues. You should also make a warm handoff, such as a phone call or an email, to ensure a seamless continuity of care.

6 Follow up with the patient and their family or caregivers

The final step is to follow up with the patient and their family or caregivers within 48 hours of discharge, to monitor their condition, answer any questions, and address any problems or barriers. You should also confirm that the patient has received their medications, attended their follow-up appointments, and accessed their post-discharge services and support. You should also use this opportunity to evaluate the effectiveness of the discharge plan, and make any necessary adjustments or referrals.