What Is Discharge Planning & How Does It Work?

Going home after health care services can be a complicated process. A good discharge plan is essential.. Image © Hans Neleman/Getty Images

Discharge planning is the process of making a plan for how a patient will manage his or her continued health care needs after being discharged from a hospital, nursing home, rehabilitation facility, or home health care service.

How Discharge Planning Works

Generally, discharge planning starts at the same time a patient is admitted to the hospital, nursing home, rehab facility or home health care company.

While you’re being wheeled in the front door, the employees are already thinking about how they’ll get you the services you need to be successfully discharged.

Exactly how your discharge plan works depends on your situation, your resources, your needs and your desires. For example, a new paraplegic will have a different needs and a different hospital discharge plan than someone who enters the hospital to give birth. The paraplegic will likely need extensive inpatient rehabilitation when they’re healthy enough to leave the hospital, while the new mother may need to be referred to a lactation consultant for education on breastfeeding techniques.

An Example of a Hospital Discharge Plan

Let’s take a fairly simple example of Mr. Smith. He’s admitted into the ICU with severe complications of diabetes. However, he didn’t know that he had diabetes. He’s now a newly diagnosed diabetic.

The discharge planner visits Mr. Smith and his family in the ICU as soon as he’s healthy enough to interact.

She determines that he’ll need a significant amount of education about how to manage his diabetes, do finger-stick blood testing, and possibly administer insulin. Additionally, he has very poor vision, so if he ends up requiring insulin shots, he’ll need some type of help making sure he’s taking the correct amount of insulin.

With Mr. Smith’s input, the discharge planner arranges for him to attend outpatient diabetes education classes as soon as he’s discharged home. Since Mrs. Smith has good vision and has agreed to help with Mr. Smith’s insulin injections, she’s arranged for Mrs. Smith to attend the classes with him.

The discharge planner also makes sure that Mr. Smith’s living situation is adequate to ensure he can care for himself appropriately. He has refrigeration to store his insulin. He has hot and cold running water so both he and Mrs. Smith can wash their hands before doing blood sugar checks or insulin shots.

In case Mr. Smith isn’t quite healthy enough to make it to outpatient classes when he’s discharged, the discharge planner checks Mr. Smith’s health insurance to see if it covers home health care. The back-up plan will be for Mr. Smith to receive some home visits from a visiting nurse if he isn’t physically able to make it to diabetes classes.

The discharge planner helps Mrs. Smith acquire a glucometer so Mr. Smith can do finger-stick blood sugar tests when he gets home.

Meanwhile, the hospital nurses, dieticians, and diabetes educator are working with both Mr. and Mrs. Smith every day helping them learn how to manage Mr. Smith’s diabetes.

When Mr. Smith is healthy enough for discharge, the discharge planner sets the plan into action and Mr. Smith gets the help he needs after discharge from the hospital.

Who Does Discharge Planning?

Discharge planning is frequently done by either nurses or medical social workers. However, a good discharge plan involves an entire team of people including the patient himself.

For example, the discharge planner may need the input of the physical therapist, occupational therapist, or speech therapist to help determine if a stroke patient will need inpatient rehabilitation after hospitalization or will be able to go home with home health care.

The surgeon’s input will be needed to determine how complicated the post-op care regime of a patient will be. Will there be simple dressing changes that the patient can do himself or herself? Or will there be a complicated negative-pressure electronic suction dressing that requires intermittent home visits from a wound care specialist nurse to manage?

The staff nurses and nurses’ aides contribute to the discharge planning process by helping to identify a patient’s social situation and needs. They work to meet as many of those needs before discharge as possible.  For example, it would likely be the staff nurse caring for Mr. Smith in the above example that would become aware that Mrs. Smith is an IV drug abuser. In this case, Mr. Smith’s discharge plan may need to be changed since an active IV drug abuser isn't an appropriate person to assist Mr. Smith with his insulin shots.

The utilization review nurse contributes to the discharge planning process by helping to determine how long the admission will likely be and coordinating health insurance benefits. Sometimes discharge planning is done by a case manager, usually a nurse whose position combines both utilization review and discharge planning into one job.

Discharge planning isn’t limited to hospitals, either. Nursing homes, inpatient rehabilitation facilities, behavioral health facilities, assisted living facilities and home health care companies are just some of the health care service providers that do discharge planning.

Why Is Discharge Planning Such a Big Deal?

There are several reasons discharge planning is important.

  • A good discharge plan helps patients manage their medical needs after they’re discharged so they stay as healthy as possible. Discharge plans help to prevent screw-ups like patients not understanding how to take their medications correctly or not getting appropriate follow-up.
  • A good discharge plan helps patients feel more in control and less anxious about coming home from the hospital or rehab facility, or about managing when the visiting nurse no longer visits.
  • A good discharge plan helps prevent re-admissions for the same or related medical problems. This is a big deal for hospitals since Medicare punishes a hospital financially when patients "bounce back" and are re-admitted to the hospital for the same problem not long after discharge.
  • Starting the discharge planning process at the time of admission, or even before admission if possible, avoids discharge delays and prevents unnecessarily long hospital, rehab, or home health admissions. A good example of starting the discharge planning process before admission happens when orthopedic surgeons require patients getting knee replacements to attend a preoperative class where they learn about the recovery process and discuss options for postoperative rehab. This gives the patient time to visit inpatient rehab facilities or check out different home health care providers before the date of the surgery.
  • A good discharge plan saves both the patient and health insurance company money and frees up precious health care resources for others.

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