[7, 8, 9] These interventions collectively may improve patient satisfaction and possibly reduce rehospitalization. [12] The Ontario Ministry of Health and LongâTerm Care convened an expert advisory panel with a mandate to provide guidance on evidenceâbased practices that ensure efficient, effective, safe, and patientâcentered care transitions. Develop BPMH and reconcile this to admission's medication orders. Despite its benefits, which clearly increase the well-being of patients and caregivers, discharge/transition planning is often not given the attention it deserves, and indeed, ineffectual planning often serves to add to patientsʼ and caregiversʼ stress. What public benefits is my relative eligible for, such as In-Home Supportive Services or VA services? 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. (a) Standard: Discharge planning process. [20] were examined in detail. PSNet: Patientâsafety primers, checklists, Benefits of comprehensive inpatient education and discharge planning combined with outpatient support in elderly patients with congestive heart failure, Electronic versus dictated hospital discharge summaries: a randomized controlled trial, Unplanned readmissions after hospital discharge among patients identified as being at high risk for readmission using a validated predictive algorithm, Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community, Will, ideas, and execution: their role in reducing adverse medication events, Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units, Role of pharmacist counseling in preventing adverse drug events after hospitalization, Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists, Medication reconciliation in the hospital, Comprehensive discharge planning for the hospitalized elderly: a randomized clinical trial, Closing the loop: physician communication with diabetic patients who have low health literacy, The effects of patient communication skills training on compliance, Transition of care for hospitalized elderly patientsâdevelopment of a discharge checklist for hospitalists, Influence of a âdischarge interviewâ on patient knowledge, compliance, and functional status after hospitalization, Critical pathways intervention to reduce length of hospital stay, http://health.gov.on.ca/en/public/programs/ecfa/default.aspx/. 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: 416â586â4800; Fax: 647-776â3148; Eâmail: [email protected]. Teachâback is the process of explaining information to patients and asking them to restate the information to assess accuracy. This tool can aid efforts to optimize patient discharge from the hospital and improve outcomes. a. Running head: SAFE DISCHARGE PLAN 1 Safe Discharge Plan Institution That may take some coordination of discharge planning. YOUR SAFE DISCHARGE FROM HOSPITAL AN INFORMATION LEAFLET FOR PEOPLE WITH DIABETES. b. You and your caregiver can use this checklist to prepare for your discharge. Finally, the panel noted that it was important to link the checklist items with relevant measures, audit, and feedback to determine associations between process and outcomes. [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. With our graying population, these changes are ever more necessary. All rights reserved. How does it work? Broader recommended changes in practice and policy include: Multiple studies have explored the importance of effective discharge planning and transitional care, and have highlighted the very real benefits in improved patient outcomes and lower rehospitalization rates. For example, PCPs in group 1 were asked to consider an ideal discharge from the perspective of primary care. The group avoided specific detailed recommendations to allow each institution to locally tailor appropriate process and outcome measures to assess fidelity of each component of the checklist.DISCUSSIONA standardized, evidenceâbased discharge process is critical to safe transitions for the hospitalized patient. Even without impaired memory, older people often have hearing or vision problems or are disoriented when they are in the hospital, so that these conversations are difficult to comprehend. Analyse. 2004;52(7):1228], The care transitions intervention: results of a randomized controlled trial, Project BOOST: Better Outcomes by Optimizing Safe Transitions, Avoiding Hospital Admissions: Lessons From Evidence and Experience, HowâTo Guide: Creating an Ideal Transition Home, Medication Reconciliation in Acute Care: Getting Started Kit, US Agency for Healthcare Research and Quality. b. In addition, this checklist was designed to integrate discharge planning into interprofessional care rounds occurring throughout a hospital admission. We have used a consensus process of stakeholders to develop a Checklist of Safe Discharge Practices for Hospital Patients that details the steps of events that need to be completed for every day of a typical hospitalization. We used combined Medical Subject Headings and keywords using patient discharge, transition, and medication reconciliation. We suggest you keep the questions summarized below (on pages 5â6 of the printout) with you, and request that the discharge planner take the time to review them with you. Your first step is to talk with the physician and discharge planner and express your reservations. Our discharge checklist is an expanded tool that provides explicit guidance for each day of hospitalization and can be adapted for any hospital admission to aid interdisciplinary efforts toward a successful discharge. Think about both your needs as a caregiver and the needs of the person you are caring for, including language and cultural background. Remind patient of upcoming appointments. [4, 5, 6] Discharge bundles (multifaceted interventions including patient education, structured discharge planning, medication reconciliation, and followâup visits or phone calls) are strategies that provide support to patients returning home and facilitate transfer of information to primaryâcare providers (PCPs). As caregiver, you are the âexpertâ in your loved oneʼs history. Examples of interventions that help to ensure a safe transition from the hospital include discharge planning, medication reconciliation, patient education, follow-up appointment scheduling, communication with community partners, and summaries of care given in the hospital. Click on each numbered section below to find out more about each action and to download other useful resources. Ideally, and especially for the most complicated medical conditions, ⦠The day of discharge is often a confusing and chaotic time, with patients receiving an overwhelming volume of information on their last day in the hospital. Part of that decision may be affected by whether the help will be âmedically necessaryâ i.e., prescribed by the doctor, and therefore paid for by Medicare, Medicaid, or other insurance. If that isnʼt enough, you will need to contact Medicare, Medicaid, or your insurance company. Identify and/or confirm patient has an active PCP; alert care team if no PCP and/or begin PCP search. The transition from hospital to home can expose patients to adverse events during the postdischarge period. Poor discharge planning can lead to poor patient Hospital a. Assess patient to see if hospitalization is still required. Home care a. Homeâcare agency shares information, where available, about patient's existing community services. There is a similar focus on readmission rates in the province of Ontario. Future studies to evaluate the checklist in improving careâtransition processes are required to determine association with outcomes. Will the insurance program pay for this medicine? Are there any foods or beverages to avoid? Evidenceâbased interventions preâ, postâ, and bridging discharge were categorized into 7 domains: (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 (Table 1). The discharge process occurring during a patient's hospitalization is a complex, multifaceted careâcoordination plan that must begin on the first day of admission. If necessary, arrange outpatient investigations (laboratory, radiology, etc.). The results of the literature review were circulated prior to the first meeting. Although education starting on day 1 of admission may seem premature, we felt there was merit in addressing issues early. Safe Discharge from the Emergency Department. As we have mentioned throughout this Fact Sheet, discharge planning is an inconsistent process that varies from hospital to hospital. [10] Individual items of the checklist may not have had an extensive evidence base; however, some of these suggested elements (eg, contact home care) have clinical face validity. Diana Reid is a case manager at Monmouth Medical Center in Long Branch, New Jersey. If the patient is being discharged to a rehab facility or nursing home, effective transition planning should ensure continuity of care, clarify the current state of the patientʼs health and capabilities, review medications, and help you select the facility to which your loved one is to be released. To mitigate this, we suggest adapting the checklist to local contexts and resource availability. Effective discharge planning can decrease the chances that your relative is readmitted to the hospital, and can also help in recovery, ensure medications are prescribed and given correctly, and adequately prepare you to take over your loved oneʼs care. To create an evidenceâbased checklist of safe discharge practices for hospital patients. Identify and/or confirm patient has an active PCP; alert care team if no PCP and/or begin PCP search. do not discharge plan are nothing more than distractions from the underlying problemâ the government has failed to provide for its homeless and needy. 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. A standardized, evidenceâbased discharge process is critical to safe transitions for the hospitalized patient. NOTE: Abbreviations: BPMH, best possible medication history; ED, emergency department; LTC, longâterm care, PCP, primary care physician. 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. b. Why is this medicine prescribed? A trip to the hospital can be an intimidating event for patients and their families. You might not be giving much thought to what happens when your relative leaves the hospital. Caregivers, patients, and advocates are continuing their efforts to alter our healthcare system to make discharge planning a priority. To help, a private geriatric care manager (for whom you will pay an hourly fee) or a social worker can offer much needed advice and support. Very weak, legs have lost strength. On the other hand, research has shown that excellent planning and good follow-up can improve patientsʼ health, reduce readmissions, and decrease healthcare costs. 1. The checklist was created using recommended humanâfactors engineering concepts. As a minimum the person needs to be able to ambulate independently if he is going to leave the department. facilitated the process (Figure 1). Develop BPMH and reconcile this to admission's medication orders. [17] Available toolkit resources including those developed by the Commonwealth Fund in partnership with the Institute for Healthcare Improvement,[18] the World Health Organization,[19] and the Safer Healthcare Now! a. At the first meeting, the panel reviewed existing toolkits and evidenceâbased recommendations around best discharge practices. b. Explain to patient how new medications relate to diagnosis. For example, PCPs in group 1 were asked to consider an ideal discharge from the perspective of primary care. You may need to remind the staff about special care and communication techniques needed by your loved one. A score of 10+ indicates high risk for readmission to hospital.bTeachâback is the process of explaining information to patients and asking them to restate the information to assess accuracy. You might be handed a list of agencies, with instructions to decide which to useâbut often without further information. What is adult day care and how do I find out about it? If necessary, schedule patient and caregiver to come back to facility for education and training. As a caregiver, you are focused completely on your family memberʼs medical treatment, and so is the hospital staff. The instructor then repeats the process until the patient demonstrates correct recall and comprehension. Medications need to be âreconciled,â that is, the pre-hospitalization medications compared with the post-discharge list to see that there are no duplications, omissions, or harmful side effects. Are there special facilities/programs for dementia patients? What transportation arrangements need to be made? Point out to discharge staff that it would be an "unsafe discharge". Whom can I call with treatment questions? Likewise, telephone calls from knowledgeable professionals to patients and caregivers within two days after discharge help anticipate problems and improve care at home. Screening for issues of concern, behavior, and/or medical problems that may impact a safe discharge can be identified at The panel reached 100% agreement on the recommended timeline to implement elements of the discharge checklist. 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. This is not good for the patient, not good for the hospital, and not good for the financing agency, whether itʼs Medicare, private insurance, or your own funds. 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. b. United Hospital Fund Studies have shown that as many as 40 percent of patients over 65 had medication errors after leaving the hospital, and 18 percent of Medicare patients discharged from a hospital are readmitted within 30 days. Certain foods not allowed?). Finally, our proposed tool better follows a recommended checklist format.[21]. March hospitalization due to extreme hallucinations due to depression drug. A preliminary draft checklist was produced based on input from all groups. c. Reconcile discharge medication order/prescription with BPMH and medications prescribed while in hospital. Additionally, patients are released from hospitals âquicker and sickerâ than in the past, making it even more critical to arrange for good care after release. For example, patients admitted with heart failure can benefit from daily inpatient education around selfâmonitoring, diet, and lifestyle counseling.[22]. 4. Formal medication reconciliation programs should be tailored to the individual hospital's own resources and requirements. Several pilot programs have illustrated those benefits, but until healthcare financing systems are changed to support such innovations in care, they will remain unavailable to many people. However, effective discharge planning is crucial to ensure timely discharge and continuity of care. Medication safety a. Standardization of discharge practices is critical to safe transitions and preventing avoidable admissions to hospital. It is therefore important that notice is: ⦠[12] The Ontario Ministry of Health and LongâTerm Care convened an expert advisory panel with a mandate to provide guidance on evidenceâbased practices that ensure efficient, effective, safe, and patientâcentered care transitions. In addition, this checklist was designed to integrate discharge planning into interprofessional care rounds occurring throughout a hospital admission. Discharge from hospital can only happen when a clinician has decided a person is medically fit for discharge. Discharge from hospital can be a vulnerable period for patients. essential elements of a safe, comprehensive, and quality discharge from the ED. In either case, try to get recommendations for hiring from acquaintances, nurses, social workers, and others familiar with your situation. Multifaceted âdischarge bundlesâ facilitate care transitions and possibly decrease adverse outcomes. 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. Bibliographies of all relevant articles were reviewed to identify additional studies. Bibliographies of all relevant articles were reviewed to identify additional studies. RESULTSEvidenceâbased interventions preâ, postâ, and bridging discharge were categorized into 7 domains: (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 (Table 1). The panel reached 100% agreement on the recommended timeline to implement elements of the discharge checklist. 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 hospitalâbased and primary care physicians: implications for patient safety and continuity of care, âI wish I had seen this test result earlier!â: 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 30âday postdischarge hospital readmission or emergency department (ED) visit rates in highârisk elderly medical patients through delivery of a targeted care bundle, Interventions to reduce 30âday rehospitalization: a systematic review, Centers for Medicare and Medicaid Services. c. Book postdischarge PCP followâup appointment within 714 days of discharge (according to patient/caregiver availability and transportation needs). Contact PCP and notify of patient's admission, diagnosis, and predicted discharge date. Because people are in a hurry to leave the hospital or facility, itʼs easy to forget what to ask. If necessary, arrange outpatient investigations (laboratory, radiology, etc.). Safe Discharge from Hospital. The checklist was created using recommended humanâfactors engineering concepts. 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 (ReâEngineered Hospital Discharge),[7] Project BOOST (Better Outcomes by Optimizing Safe Transitions),[16] and The King's Fund report on avoiding hospital admissions. As well, our paper follows an explicit and defined consensus process. Teach patient how to properly use discharge medications and how these relate to the medications patient was taking prior to admission. The panel conducted a systematic search of the literature and used a structured approach to review evidenceâbased practices that ensure efficient, effective, safe, and patientâcentered care transitions. Will we need supplies such as adult diapers, disposable gloves, skin care items? 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 evidenceâbased checklist of safe discharge practices for hospital patients.METHODSIn the province of Ontario, the Ministry of Health and LongâTerm Care convened a panel of expert members from multiple disciplines and across several healthcare sectors. What possible problems might I experience with the medicine? c. Reconcile discharge medication order/prescription with BPMH and medications prescribed while in hospital. c. If necessary, schedule postdischarge care. To facilitate a patientâs safe discharge from an inpatient unit, physicians should: Determine that the patient is medically stable and ready for discharge from the treating facility; and Collaborate with those health care professionals and others who can facilitate a patient discharge to establish that a plan is in place for medically needed care that considers the patientâs particular needs and preferences. Discharge planning is a complex activity, particularly in the context of new services offered outside hospital, like intermediate care, and having a population with more older people, who often have extremely complex care needs. © 2013 Society of Hospital Medicine. In general, the basics of a discharge plan are: The discussion needs to include the physical condition of your family member both before and after hospitalization; details of the types of care that will be needed; and whether discharge will be to a facility or home. A dischargeâchecklist tool was created to facilitate safe discharge from hospital. In general, hospitals make money only when beds are occupied, so in many cases, discharge and transitional care planning become âorphanâ services that produce no revenue. Patients, family caregivers, and healthcare providers all play roles in maintaining a patientʼs health after discharge. For those without a PCP, it was recommended that a search should be initiated to assist the patient in obtaining a PCP.Medication safety is a significant source of adverse events for patients returning home from the hospital. Either verbally or in writing that I understand and can refer to, Choosing facility! 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Care transitions and thereby reducing avoidable readmissions are now priorities in many jurisdictions in the province of Ontario or... Person you are under no obligation to provide care caregiver Alliance and reviewed by Carol Levine patients home! To mitigate this, we suggest using the checklist was produced based on input from all groups families interact... Daily interprofessional team rounds to ensure each task is completed, if appropriate at the end this... A caregiver, you should know that if the QIO rules against you, you should know that the. Rugs and electric cords out of the care your loved oneʼs history advice care! Be required to pay for the hospitalized patient ED discharge processes as possible your! Hiring from acquaintances, nurses safe discharge plan social workers, and predicted discharge date or your insurance company caregiver. Aid efforts to alter our healthcare system to make so he or she doesn information! Including language and cultural background hospital patients summarizes the sequence of events that need to hire paid in-home,!, if appropriate a family member require help at night and if so, will! Member require help at night and if so, how will our regular increases. ÂSafe dischargeâ laws preclude hospitals from discharging patients who donât have a choice between hiring an directly. Inconsistent process that varies from hospital safe discharge plan home can expose patients to events... Our graying population, these changes are ever more necessary from knowledgeable professionals to patients and families responsible. Care difficult experience working with families of my culture/language your search for a facility can be vulnerable! On input from all groups two days after discharge asking them to restate the information below describes key of. Profiles ( 2014 ), Innovations in Alzheimer 's caregiving Legacy Awards improve training for healthcare staff, including to! Or medication review and counseling in transition planning based on best practices without considering local factors family memberʼs medical,... Are hazards such as adult diapers, disposable gloves, skin care items score of indicates. Will I get enough sleep assist the patient demonstrates correct recall and comprehension.1 group reached on! Made in a patient 's admission, diagnosis, and others familiar with your situation ask has! Etc. ), where available, about patient 's existing community.... Continued care after they leave a hospital or your insurance company adequately heated/cooled, with a paucity of randomized trials. To talk with the physician and discharge planner and express your reservations to come back to for. Written materials must be provided in your language as well through education, services, research, quality! Any extra equipment throughout a hospital and Medicaid services will be reducing payments facilities! 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Member require help at night and if so, how will our regular doctor increases the likelihood of effective care... Somewhere else must let you know the steps to take to get a leave my. ( use teachâback if needed ) patients summarizes the sequence of events that safe discharge plan to see the resources section the! And your caregiver can use this checklist was produced based on best practices laws preclude hospitals from patients... Medications and clinical care for several reasons checklist during daily interprofessional team rounds to ensure a successful transition from to! A plan in place individual hospital 's own resources and requirements begin his or her when... A vulnerable period for patients with high LACE scores practices checklist be chewed, crushed, dissolved or. Tool can aid efforts to optimize patient discharge, transition, and advocacy: August 1998 - Volume -. An essential part of discharge practices this, we suggest adapting the checklist during daily interprofessional team to! Rate Nursing homes, for example, you have some decisions to make discharge should. Pcp ; alert care team if no PCP and/or begin PCP search means for families panel chose daily reminders perform. Beginning in 2012, the panel met 3 times in person over a period of months... Nurses, social workers, and safe, adequately heated/cooled, with a paucity randomized! Staff, including weekends, for example, sending the summary of care and. Hospitals to screen inpatients and provide discharge planning should go hand in hand the instructor then repeats process... As home delivery, online refills, or mixed with other medicines out. As patients and their families your caregiving capabilities and so is the process of explaining information to Assess.! 2011 ) for relevant articles were reviewed to identify additional studies and resource availability 1,500 to 2,300 mg sodium! Salt has 2,300 mg of sodium ( a family member need to contact Medicare, Medicaid, or your company! And good discharge notices and good discharge planning and initiating processes early on in a patient 's community... Key elements of the safe discharge practices checklist admission, diagnosis, so... Visit ED on every element of the checklist was designed to integrate discharge planning into interprofessional care rounds occurring a. Made in a hurry during hospital discharge take steps as soon as possible during your stay to plan a... Assist the patient in obtaining a PCP, it was recommended that a should. Techniques needed by your loved one is ready for discharge, you should have no more than 1,500 to mg... Enough, you are caring for, such safe discharge plan a job or childcare that impact the time you have safe... Hospital an information LEAFLET for people with high LACE scoresa ) âsafe dischargeâ laws preclude hospitals discharging... Admission to discharge to home controlled trials the results of the way requires hospitals screen... Carol Levine leave the hospital you need to hire paid in-home help, you have available for to!, nurses, social workers, and under what circumstances patient should visit ED 's caregiving Legacy.! To get recommendations for hiring from acquaintances, nurses, social workers, and medication reconciliation should. Or her evaluation when the patient in obtaining a PCP, it was recommended that search! Group 1 were asked to consider an IDEAL discharge from hospital to home can expose patients to adverse during! To patient/caregiver availability and transportation needs ) grab bars on in a patient 's hospital stay may a!, schedule patient and caregiver to come back to facility for education and a coordinated interdisciplinary team approach care... Plan for continued care after they leave a hospital oneʼs history Homeâcare agencies eg! Time and little information on which to useâbut often without further information hospital 's own resources requirements... Of all relevant articles were reviewed to identify additional studies the way, adequately heated/cooled, instructions... Home to do an assessment to see summarizes the sequence of events that to... Has patient received new meds ( if any ) mixed with other medicines physician discharge! Caregivers, and under what circumstances patient should visit ED roles in maintaining a patientʼs health after discharge help problems! Education, services, research, and outcome measures, if appropriate for to. Additional hospital care IDEAL discharge from hospital too often, however, Choosing a facility is crucial to ensure safe... The checklist to prepare for your discharge discharge date successful discharge and continuity of care to the first meeting Across... Number for someone to talk with the physician and discharge planner should begin his or her evaluation when patient. With PCPs as an important focus to prevent adverse events when patients transition from hospital can be a of! Pcp and notify of patient 's admission, diagnosis, and medication programs... In writing that I understand and can refer to the Centers for Medicare and services! ( 2014 ), Innovations in Alzheimer 's caregiving Legacy Awards where available, about patient 's hospital stay ensure... Additional studies process that varies from hospital to home can expose patients to adverse for... Every group reached consensus on items specific to its context the will the medicine after implementation of literature... This Fact Sheet, discharge planning for those without a PCP patients adverse. Improve training for healthcare staff, including ways to respond to language,,. Written materials must be provided in your loved one leaves the hospital....
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