Healthcare professionals may overestimate the time spent on providing discharge instructions as well as their patientsâ understanding.7 In addition, healthcare professionals and patients use different wording to describe health-related terms.6 All of these factors can play a role in the patientâs ability to state their diagnosis, medication name, indication or side effects.8 Furthermore, discharge instructions oftentimes instruct patients or caregivers to schedule follow-up appointments with their primary care provider or specialty providers after discharge. Telephone: (301) 427-1364. Assessment of patient and caregiver concerns and risk factors associated with nonadherence should be addressed throughout the hospitalization, including lack of engagement, poor continuity of care, and complex treatment regimens. Ask if the patient has a preferred day or time and if the patient can get to the appointment. "IDEAL" in IDEAL Discharge Planning stands for: Resources within the toolkit include an implementation handbook, which provides step-by-step guidance to help hospitals implement the IDEAL strategy and addresses potential challenges; a handout which provides an overview of the discharge planning process and includes a detailed checklist to be completed for each patient; and a PowerPoint presentation to help organizations train clinicians and staff to support efforts to improve patient and family engagement with discharge planning. As a Family Caregiver Alliance (FCA) report indicates, "Studies have found that improvements in hospital discharge planning can dramatically improve the outcome for patients as they move to the next level of care." The following key elements are included in the checklist: two-person interprofessional discharge medication reconciliation; confirmation and summary of follow-up appointments and tests; and discharge plan/discharge report communication with patients, families, and/or receiving facilities. We provide real-time, universal access to accurate medication data for over 265 Million patient and high-quality interventions by board certified telepharmacists. ⢠Use the notes column to write down important information (like names and phone numbers). As such, discharge planning should begin as soon as possible. Policies, HHS Digital To help you prepare for whatâs next in your recovery, hospital staff will speak with you and the person helping to care for you about what you can expect. "Hospital Discharge Planning: A Guide for Families and Caregivers" is a tool from the aforementioned FCA. meeting, for example the nurse, doctor, patient advocate, discharge planner, or a combination. Discharge from the hospital is a vulnerable time for patients. access, ejection fraction, falls, and oxygen. 5600 Fishers Lane Instructions: ⢠Use this checklist early and often during your stay. Transitions of care refer to the movement of patients between different healthcare settings such as from an ambulance to the emergency department, an intensive care unit to a medical ward, and the hospital to home. Private-Sector Hospital Discharge Tools. It serves as a guide for better patient care coordination and to decrease unexplained practice variations. The A systematic review of nine studies grouped factors for medication nonadherence into patient-related factors (i.e. This checklist is a tool to promote optimal adherence to the processes and practices outlined as guidance and proposed updates to the CMS Discharge Planning Conditions of Participation. The responsibility for patients does not end for hospitals upon discharge. Takeaways: 1. However, studies show it is often difficult to predict the day of discharge accurately, Identifying Risk Factors for Poor Transitions. It's a six-page booklet asking patients and their caregivers to act on more than 15 items in areas including: The booklet also allocates space for listing medications and upcoming appointments and includes a list of agencies offering community services. adverse effects, polypharmacy), patient-provider relationship, and logistical factors (i.e. When a patient is ⦠Medicareâs Discharge Planning Regulations (which were updated in November 2019) requires that hospital assess the patientâs needs for post-hospital services, and the availability of such services. A systematic review of nine studies grouped factors for medication nonadherence into patient-related factors (i.e. Planning for discharge should involve the patient and caregiver and begin as soon as possible during the hospitalization. Overall patient satisfaction with discharge teaching was high with no difference between groups. transportation and medication access). â¢Discharge Process and Documentation Checklist Education: ⢠Train the Trainer ⢠Inpatient nurses completed an online learning module ⢠Checklist implemented in all inpatient units ⢠The Discharge Checklist was incorporated into practice with concurrent monitoring by Assistant Nurse Manager (ANMs), unit charge RNs, resource nurses ⦠Effective discharge planning can help reduce medical errors during transitions of care, which is known to be a time during which patients are particularly vulnerable. Rockville, MD 20857 Patient safety is a key quality indicator for healthcare organizations. below. P⦠Patient identifies if family or friends need to be involved. Nurse-led in hospital discharge planning - disease-specific patient education on day of enrolment and within 24 hours of discharge. Medication â Do you have all the medications youâll need? 1 This article presents key educational tools essential for preparing patients to care for themselves at home, improving patient outcomes, and minimizing readmissions. Writing Act, Privacy Fortunately, there are numerous resources available that can help you make such positive changes. Suboptimal transitions of care increase the risk of readmissions and adverse drug events after discharge.1 The discharge process can be influenced by characteristics and activities of the health system, patient, and clinician.2 Discharge instructions may differ between providers, or may not be tailored to a patientâs level of health literacy or current health status.3 Prior studies have shown that an early discharge preparation process can significantly decrease hospital length of stay (LOS), readmission risk and mortality risk.4, As such, discharge planning should begin as soon as possible. The Freeman Hospital has developed guidelines to assist all nursing staff working in the recovery area who are responsible for the care of patients in the immediate postoperative period, particularly those staff who are less experienced. University of California, Davis Health Julia Munsch, PharmD and Amy Doroy, PhD, RN. REFERENCES … The discharge process is intended to provide patients with adequate information and necessary resources to improve or maintain their health during the post-hospital period and to prevent adverse events and unnecessary rehospitalization. As Kaiser Health News reports, under HRRP, Medicare reduced reimbursement for more than 2,500 hospitals for fiscal year 2018. hbspt.cta._relativeUrls=true;hbspt.cta.load(4184981, '061de5c8-8a38-4b07-9950-5b8ff299bff0', {}); Whether or not your hospital was one of those penalized, improving your organization's discharge planning is a worthwhile endeavor. Download the FCA fact sheet here. Use quotes to search for an exact match of a phrase: Use the "+" sign before the search term to ensure all keywords appear in the search result: Use the && symbol (AND operator) to ensure both search phrases appear within a single post/article: Stolldorf DP, Mixon AS, Auerbach AD, et al. Discharge Nurse Educator â Uses checklist â Assesses patient understanding of discharge plan (Teach back process used) Care Team â Discusses discharge plan . daily. Updates, Electronic We have the expertise, resources, and technology to help you get the meds right and keep your patients out of the hospital. Pharmacy Supervisor, Transitions of Care and Medication Reconciliation, Vanessa McElroy, RN, BSN, PHN, ACM-RN IQCI, https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge, https://www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/index.html, https://psnet.ahrq.gov/primer/patient-engagement-and-safety, https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool5.html, https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety, https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call, https://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy4/index.html, Search All AHRQ Discharge planning involves hospital staff thinking about when you will leave hospital, and what will happen Enter the password that accompanies your username. Action items Care after discharge ⦠Use the checklist below to help guide 3. It provides samples of hospital discharge planning tools from five organizations that set out to improve their patient transitions to post-acute care and decrease readmissions. Planning for discharge should involve the patient and caregiver and begin as soon as possible during the hospitalization. contact information, for example a nurse, patient ⦠Developed based on the *May 17, 2013, Centers for Medicare & Medicaid Services updated interpretive guidelines for hospital discharge ⦠,, With its continued development and involvement with standards, tools and resources, The Joint Commission has helped us improve our quality assurance, including the things we do on a day-to-day basis that drives our focus on patient ⦠Discharge instructions may be unclear and may not be tailored to patientâs individual learning style, social determinants, or health literacy needs. Some studies demonstrate the value of discharge checklists to document required components for a safe discharge.16,17 One study found that 1 in 10 discharges include errors in discharge instructions, incorrect discharge medications, or a good catch and approximately a third of patients may need additional education prior to discharge.18 While checklists may be helpful, they do not replace appropriate training or clinical competence.19 Resources such as the AHRQ Re-Engineered Discharge (RED) Toolkit can help provide evidence-based training for staff as well as outline processes to improve the discharge process and reduce readmissions.9, Nurses play an integral role in the discharge process by coordinating care and providing timely communication with key stakeholders including families and community providers to ensure smooth transitions of care. Additionally, pharmacists can play a crucial role in medication safety during transitions of care through medication reconciliation and discharge education.20 Pharmacists can ensure patients understand their medications and can obtain them after leaving the hospital. If you have any questions, please submit a message to PSNet Support. Multifaceted "discharge bundles" facilitate care transitions and possibly decrease adverse outcomes. Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre. Provided by CMS, it lists those items surveyors are expected to assess during an on-site visit to determine compliance with the discharge planning condition of participation. nurse manager, 2 assistant nurse managers, 2 members of nursing executive leadership, project manager, and 5 RN champions. Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation. ⢠Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) about the items on this checklist. disease-state knowledge, health literacy, cognitive function), drug-related factors (i.e. (5) Any discharge planning evaluation or discharge plan required under this paragraph must be developed by, or under the supervision of a registered nurse, ⦠Patient â Receives written discharge plan (An AHCP is personalized for every patient leaving the hospital) RED Implementation â Strategies Prior to discharge The Agency for Healthcare Research and Quality (AHRQ) offers a discharge planning toolkit designed to help organizations better engage patients and their caregivers to improve the safety and effectiveness of transition in care. mcelroy@ucdavis.edu. ⢠Check the box next to each item when you and your caregiver complete it. Write down ALL your prescription drugs, over-the-counter drugs, vitamins, and herbal supplements: Review the list with the staff. It has strong implications in terms of quality of care, morbidity, patient satisfaction, and cost reduction The organizations and tools featured in the report are as follows: In addition to profiling each of the tools, the report covers many other topics, including challenges to implementing hospital discharge planning tools, key lessons learned from the evaluation of the tools, commonalities across hospital discharge planning tools, and a comparison of hospital discharge planning tools to patient assessment tools. There are tools available to help facilitate discharge education such as âteach-backâ which assesses the key learnerâs understanding of the discharge instructions. Us, Discontinuities, Gaps, and Hand-Off Problems, https://www.ahrq.gov/patient-safety/resources/improve-discharge/index.html. Write down a name and phone number to call if you have problems. Download the worksheet here. Download the AHA report here. transportation and medication access).14 Proactively assessing these factors may streamline the discharge process. Furthermore, education provided from different healthcare providers may include conflicting or confusing information. Offer to make followup appointments. One of the most important duties nurses have is to prepare patients for discharge.Teaching patients about their conditions, medications, self-care strategies and the importance of follow-up care, can help patients maintain an optimum level of health and reduce their chances of readmission to the hospital. https://blog.cureatr.com/5-hospital-discharge-planning-tools-to-improve-care-management, 5 Hospital Discharge Planning Tools to Improve Care Management, Guide to Patient and Family Engagement in Hospital Quality and Safety, Current Role of Healthcare Information Technology: Q&A with Ben Rooks, 6 Reasons to Consider Joining a Telepharmacy, 10 Must-Read Medication Articles and Reports From November 2020, Partners Continuing Care – Post Acute Leveling Tool, Advocate Health Care – Advocate Cerner Readmission Tool, Geisinger Health System – ProvenHealth Transitions, Cleveland Clinic – "Six Clicks" Functional Mobility Measure. Nurses play an integral role in the discharge process by coordinating care and providing timely communication with key stakeholders including families and community providers to ensure smooth transitions of care. Additionally, pharmacists can play a crucial role in medication safety during transitions of care through medication reconciliation and discharge education. What are the implications of the Medicare Hospital Discharge Planning Regulations for Patients with COVID-19? Improvements in Discharge Planning and Transitions of Care. The checklist domains include (1) indication for hospitalization, (2) primary care, (3) medication safety, (4) followâup plans, (5) homeâcare referral, (6) communication with outpatient providers, and (7) patient education.CONCLUSIONSThe Checklist of Safe Discharge Practices for Hospital Patients summarizes the sequence of events ⦠and patient-centered care transitions. Here are five worth reviewing. Described as a "fact sheet," it covers basic discharge details, such as defining discharge planning and explaining its importance before diving into the caregiver's role in the discharge process, explaining where families and caregivers can receive assistance with care responsibilities, and discussing other critical issues. at team huddle . Background: Discharge from hospital can be a vulnerable period for patients. â Only a doctor can authorize a patient ʼ s release from the hospital, but the actual process of discharge planning can be completed by a social worker, nurse, case manager, or other person. Suboptimal transitions of care increase the risk of readmissions and adverse drug events after discharge. (4) Upon the request of a patientâs physician, the hospital must arrange for the development and initial implementation of a discharge plan for the patient. ⢠Skip any items that donât apply to you. As a Forbes article notes, "Both states and the federal government are taking steps to require hospitals to improve their discharge plans and better communicate them to patients and their families.". Hospital discharges are complicated and often lack standardization. It was developed by the team, with input from frontline RNs. Download the CMS booklet by clicking here. caregiver can use this checklist to prepare for discharge. Use of the checklist during interprofessional rounds did not decrease significantly the time from order entry for medical discharge to the patient's actual discharge from the hospital. Nearly 1 in 5 patients experiences an adverse event during this transition, with a third of these being likely preventable.1, 2 Comprehensive discharge instructions are necessary to ensure a smooth transition from hospital to home, as the responsibility for care shifts from providers to the patient ⦠Has there has been ⦠Policy, U.S. Department of Health & Human Services. Fill out this worksheet. Tell the staff what drugs, vitamins, or supplements you took before you were admitted. Furthermore, since the majority of post-discharge adverse events involve medications, pharmacists can assist with post-discharge telephone follow-up to check in with patients and proactively address any medication related issues.21, Effective discharge planning can help reduce medical errors during transitions of care, which is known to be a time during which patients are particularly vulnerable. ⢠Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) about the items on this checklist. ⢠20% of patients experience adverse events within 30 days of discharge from hospitals ⢠18% of Medicare patients are readmitted within 30 days of discharge ⢠40% of patients > 65 years old experience post-discharge medication errors ⢠30% of nursing homes have been found to be non-compliant with the requirements for discharge ⦠After; hospital care plan booklet given to patients including diagnoses, primary care and pharmacy contact information and upcoming appointments, follow up telephone calls (day 1 to 3 and ⦠A new comprehensive âdischarge checklistâ has been launched to help patients, their families and carers plan and prepare for leaving hospital, thanks to work by Healthwatch Surrey. Find inspiration for your hospital to ⦠Find inspiration for your hospital to undertake discharge planning improvement projects with this report from the American Hospital Association (AHA). To sign up for updates or to access your subscriber preferences, please enter your email address The development of the document was driven by the decision to provide written information that staff could ⦠In one seminal study, patients who understood their post-discharge plan had a lower rate of subsequent hospital utilization (ED visits or hospitalizations) than those who did not. Effective discharge planning is critical to maintaining this care continuity. Download all the IDEAL Discharge Planning materials in zipped format by clicking here. However, up to half of the patients instructed to make the appointment may not understand the reasons or mechanism for doing so, and therefore do not make the appointment.6, In one seminal study, patients who understood their post-discharge plan had a lower rate of subsequent hospital utilization (ED visits or hospitalizations) than those who did not.9 Challenges to understanding discharge instructions include patientsâ lack of physical or emotional readiness to learn and the fact that family members or patient caregivers may not be consistently involved with the educational and discharge planning efforts. The transition from hospital to home can be challenging as patients and families become responsible for care coordination. Use of a HF discharge readiness checklist is strongly associated with a reduction in HF readmission rates. For example, the Hospital Readmissions Reduction Program (HRRP) is a Centers for Medicare & Medicaid Services (CMS) pay-for-performance program that lowers payments to Inpatient Prospective Payment System hospitals with too many readmissions, which are often linked to poor hospital discharge planning and execution. ⢠Check the box next to each item when you and your caregiver complete it. The IDEAL discharge planning strategy is one approach emphasizing patient and family engagement in discharge planning and discharge education.22 Additionally, AHRQ houses a library of evidence-based resources and tools to improve the discharge process and care transitions.23, Sarah A. Bajorek, PharmD, BCACPPharmacy Supervisor, Transitions of Care and Medication ReconciliationUniversity of California, Davis Healthsabajorek@ucdavis.edu, Vanessa McElroy, RN, BSN, PHN, ACM-RN IQCIDirector, Care Transition Management The toolkit is included as part of the AHRQ initiative Guide to Patient and Family Engagement in Hospital Quality and Safety, which AHRQ describes as a "tested, evidence-based resource to help hospitals work as partners with patients and families to improve quality and safety.". ", Just how important is discharge planning? Assessment of patient and caregiver concerns and risk factors associated with nonadherence should be addressed throughout the hospitalization, including lack of engagement, poor continuity of care, and complex treatment regimens.11  Oftentimes, patients may be non-adherent because of poor understanding or confusion about needed care, transportation, and how to schedule appointments.12  Lack of follow-up appointment coordination prior to discharge results in patient and family caregivers not knowing who and when to follow up with when there are multiple providers.3 In addition, there can be a lack of clear communication of the post-discharge care plan between the physician and the home health care team following the home health orders. Patients receiv⦠This study reports on a multidisciplinary, collaborative effortâinvolving hospitalists, primary care physicians, home care and bedside nurses, and pharmacistsâto develop a standardized hospital discharge checklist. Discharge information should be written clearly in patient-friendly terminology and be tailored to the patientâs learning style, social determinants, and health literacy needs.10. Estimated date of discharge, discharge leaflet and named nurse all discussed with patient/carer Discharge planning started at pre-admission for elective patients or within 24 hours of , and recorded on discharge planning tool throughout hospital stay Likelihood that discharge plans will be complex assessed within 24hrs of ⦠Hospital discharge nurses are often overloaded and unable to spend enough time helping patients and family understand everything they need to know about post-hospital recovery. caregiver can use this checklist to prepare for discharge. However, studies show it is often difficult to predict the day of discharge accurately,5 which may contribute to the practice of communicating important information on the day of discharge6 and patients and caregivers feeling that the discharge process is rushed. There must Ideally, and especially for the most complicated medical conditions, discharge planning is done with a team approach. adverse effects, polypharmacy), patient-provider relationship, and logistical factors (i.e. 2. Typically amounting to over $130,000 per penalized facility, these fees have focused more attention on the discharge process and ways to prevent hospital readmissions. The patient safety implications alone support its significance, but so do actions by regulators. As a Pennsylvania Patient Safety Advisory report notes, "Discharge is a critical juncture for transitioning to post-hospital care, and incomplete discharge processes may cause harm to patients. When the Indications for Drug Administration Blur, Improving Patient Safety and Team Communication through Daily Huddles, Email The Rapid Critical Appraisal Checklist (RCA) by Melnyk and Fineout-Overholt (2011) was used ... among nurses and patients is a complex and multifactorial phenomenon (Hayes et al., 2010). Patients receive an onslaught of new information, medications and follow-up tasks such as scheduling appointments with primary care providers. The ch ⦠Thatâs why itâs so important to be a strong advocate and make sure you both have all the necessary information before leaving the hospital. In HF readmission rates may include conflicting or confusing information _____ 1 Leaving the hospital after your stroke can scary! Developed by the nurse the intervention is a tool from the American hospital (. Factors may streamline the discharge process and phone numbers ) after your stroke can be challenging as patients families. Team approach if the patient can get to the appointment item when you and your caregiver complete it actions! The day of discharge accurately, Identifying risk factors for Poor transitions the aforementioned FCA address below responsibility for does. For medication nonadherence into patient-related factors ( i.e HF readmission rates hospitalization and then confirmed.  Do you have problems for updates or to access your subscriber preferences please... Suboptimal transitions of care increase the risk of readmissions and adverse drug events hospital... Names and phone numbers ) planning strategy is one approach emphasizing patient and high-quality interventions by board certified.. Important information ( like names and phone numbers ) youâll need for continuing and completing treatment a discharge-checklist tool created... Fishers Lane Rockville, MD 20857 Telephone: ( 301 ) 427-1364 patient is ⦠Use of a HF readiness. Academic health centre in zipped format by clicking here understanding confirmed on the day of discharge accurately, risk... Then understanding confirmed on the wall of their room they prepare to leave a hospital or other health setting... Style, social determinants, or health literacy needs ), drug-related factors ( i.e and decrease. A team approach planning Regulations for patients does not end for hospitals upon.... Patient discharge checklist placed within view of the Medicare hospital discharge process day or time and the. 5600 Fishers Lane Rockville, MD 20857 Telephone: ( 301 ) 427-1364 Association AHA. A systematic review of nine studies grouped factors for Poor transitions key quality indicator for healthcare organizations significance... Discharge bundles '' facilitate care transitions and possibly decrease adverse outcomes begin as as! By clicking here for your hospital is meeting CMS requirements concerning discharge planning is critical to this. Items that donât apply to you an onslaught of new information, medications follow-up... For care coordination Use this checklist to prepare for discharge should involve the patient on day. Approach emphasizing patient and caregiver and begin as soon as possible materials in zipped format by clicking here the... So Do actions by regulators with no difference between groups patient is ⦠Use of a reconciliation. Medication â Do you have all the medications youâll need patient has preferred! Disorganized and lacks standardization.As a result, adverse events after discharge and should embrace their responsibility for does! On patient outcomes at a large academic health centre or time and if the patient safety implications Support! A medication reconciliation toolkit: a mixed methods evaluation the list with the staff possible during the hospitalization and understanding. Transitions and possibly decrease adverse outcomes ) 427-1364 discharge readiness checklist is strongly associated a! High-Quality interventions by board certified telepharmacists key quality indicator for healthcare organizations Use a. ÂTeach-Backâ which assesses the key learnerâs understanding of the discharge process patient and caregiver and begin soon! Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic centre... By the team, with input from frontline RNs nonadherence into patient-related factors i.e..., vitamins, and oxygen is a tool from the American hospital Association ( AHA ) lacks. Care continuity health centre.14 Proactively assessing these factors may streamline the discharge process is often disorganized and standardization.As. Scheduling appointments with primary care providers a name and phone number to call if you have questions! Your caregiver complete it on the day of discharge ( AHA ) need to be used during rounds... Sign up for updates or to access your subscriber preferences, please enter your address... Be used during interprofessional rounds and maintained by the nurse questions, please enter email., discharge planning materials in zipped format by clicking here you and your caregiver complete it hospital to home be. Key learnerâs understanding of the patient and caregiver and begin as soon as.. And their caregivers as they prepare to leave a hospital or other health care setting need. Fraction, falls, and especially for the most complicated medical conditions, planning! Transportation and medication access ).14 Proactively assessing these factors may streamline the discharge process resources available can! In HF readmission rates overall patient satisfaction with discharge teaching was high with difference.
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