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Discharge planning starts at admission
It’s never too early to start strategizing this part of the healing process
Carole Jakucs, BSN, RN, PHN
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. And experts say the sooner discharge planning is begun, the better.
There's no time to waste
Andie Melendez, RN
“We start preparing patients for discharge at the moment of admission,” said Andie Melendez, MSN, RN, CHTP, HTCP, HSMI, RM, clinical practice development coordinator, clinical education and development at the University of Maryland Baltimore Washington Medical Center in Glen Burnie, Md., and national secretary at the Academy of Medical-Surgical Nurses.

“We do that by taking an extensive history regarding their physical, emotional, spiritual and mental needs. We look at the needs they’ll have at discharge then begin to integrate the entire clinician team to make sure we address all their needs, so they don’t have to be readmitted.” Part of gathering history is finding out if they have support once they leave the hospital. “The admission history taken by the bedside nurse that begins the discharge planning process, includes determining if patients have a safe place to go once they’re discharged,” said Marisa Streelman, MSN, RN, CMSRN, unit director, 9 South Atrium, at Rush University Medical Center in Chicago and national treasurer with AMSN.
Marisa Streelman, RN
“Finding out who will care for a patient once they go home and what their home setting is like, in addition to assessing if they’ll need PT, OT or home health nursing, helps to determine if home is the best place initially upon discharge or not,” said Streelman. “The patient may need an acute or sub-acute rehab. Multidisciplinary rounds occur daily on each patient during the week, with the goal of facilitating services for them and meeting their needs when they’re discharged.”
A thorough assessment may uncover obstacles for recovery that the patient might not even realize could be an issue. “The admission assessment identifies patients’ needs that trigger resources such as social work, a dietitian consultation and PT for example, along with assessing patients’ capabilities and general safety conditions to thrive at home,” said Olivia Mays, BSN, RN III, patient flow nurse at Vanderbilt University Medical Center in Nashville, Tenn.
Mays said her role as a patient flow nurse at Vanderbilt on a med-surg floor is to lighten the load of the bedside nurses in regard to
discharge planning
and patient education. On the weekends when she’s off duty, the bedside nurses conduct the discharge education.
Mays also assists in patient care as a med-surg nurse when needed. Otherwise, her role is focused on teaching patients about their conditions and the provision of discharge instructions, which includes updates and revisions to reflect the latest information on patients’ diagnoses, medications and follow up appointment instructions.  
During the week, Mays also participates in daily multidisciplinary huddles to uncover any barriers that exist for patients regarding their discharge home and planning to help overcome those barriers, she said.
“If patients have any barriers to getting their meds once they’re home, such as not having transportation to get to a pharmacy, this eliminates that barrier.”
— Olivia Mays, RN
Pick from many patient education tools
Education is essential to help patients take better care of themselves at home and reduce readmission rates said Streelman.
“Educating patients is the responsibility of the frontline nurse,” she said. “At Rush we use a variety of methods such as teach back, which requires patients and families to teach back to their nurse and tell him or her what they just learned, including a return demonstration of any hands-on skills that were taught. We also use approved videos with education modules accessible on TV for patients, their families and significant others, to view in their room during the patient’s admission.” The method is not a “one and done” process, either. “Teach back is an effective strategy for patients and is conducted several times with patients and their families throughout their stay, and at discharge, at Vanderbilt,” said Mays. How to draw up and inject insulin and inject Lovenox at home, are two examples of self-care skills patients may need to learn, she said. Streelman said another patient education method used at Rush are handouts with color coded zones for five of the major diagnosed conditions — CHF, renal disease, diabetes, COPD and myocardial infarctions. 
The handouts show four color zones: blue for everyday tasks patients need to do to monitor their condition; green, which indicates all is clear by listing the absence of specific symptoms — indicating their condition is under control; yellow, which signifies the patient is entering a caution/warning zone if specific symptoms are present and a call to their home health nurse or doctor for guidance is warranted; and red, which describes symptoms for their condition that are emergent and may need immediate medical attention via either a trip to the ED or by calling 911 for help. Vanderbilt also has a program called “meds-to-beds,” said Mays. If a hospitalized patient decides to obtain their discharge medications from the hospital’s pharmacy, instead of one outside the hospital, the medications are brought to the patient’s room by a pharmacy staff member and dosing instructions are given to the patient, she said.
“If patients have any barriers to getting their meds once they’re home, such as not having transportation to get to a pharmacy, this eliminates that barrier,” Mays said. “Plus, medication instructions from pharmacy staff helps to reinforce what the bedside nurse teaches during their admission, or I as a PFN gives to patients with their discharge instructions.” Follow up phone calls to patients within 48 hours of their discharge is another part of the discharge process, said Kimberly Linville, MSN, RN, nurse manager, 8 North Inpatient Medicine at Vanderbilt University Medical Center.
“Calling patients after their discharge helps to identify any gaps that may have occurred during the discharge process,” she said. “We work to resolve those gaps and also give feedback to the unit about any gaps regarding discharge. This helps to reduce readmissions.”
High readmission rates result in penalties
Michele George, RN
High readmission rates can take a financial toll on hospitals said Michele George, BSN, MBA, RN, an account manager based in Houston for Q-Centrix, a comprehensive quality data management organization based in Portsmouth, N.H. and a national director with AMSN. 
“There were three penalty programs born out of the Affordable Care Act that are Centers for Medicare & Medicaid Services initiatives that affect payments to hospitals that care for Medicare patients: The Hospital Value Based Purchasing, the Hospital Readmission Reduction Program and the Hospital Acquired Condition Reduction Program,” she said.
HVBP is an incentive program that rewards hospitals based on meeting specific quality measures said George. “If quality measures are not met, it can result in a 2% reduction in payments to the hospital from CMS. The HRRP program penalizes hospitals for excessive readmissions, which can result in a 3% reduction of payment to the organization,” she said. “
The Hospital-Acquired Condition Reduction Program examines the rates of hospital acquired infections such as but not limited to, central line-associated bloodstream infections and catheter associated urinary tract infections and penalizes hospitals with payment reductions if their infection rates are too high,” George continued.
The toll for readmission is also high for patients, said Linville. “The longer patients are hospitalized anywhere, it raises their risk for getting a hospital acquired infection. It also reduces their ability to maintain their independence. Patients don’t want to be in the hospital, they want to be home,” she said.
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Carole Jakucs, BSN, RN, PHN, is a freelance writer.
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