Discharge Planning

  1. 0
    My best friend is an RN who started out as a med-surg staff nurse, and since then, became an Admissons nurse. Now, she is part of a pilot program for discharge planning with will last about 4-6 weeks. They were very vague in what they wanted, so, in the beginning, she was doing the actual discharges in telemetry, and then, she was told by the Director of Nursing that they wanted her to let the staff nurses do the discharging and then, she is to follow up by asking the patients what their needs were, if they felt that they received the teaching necessary, and if they understood the discharge plan.

    We are both a bit bewildered on what they want. Is it that each state or Joint Commission has discharge requirements? Is there a generic form that illustrates what the expectations of the RN's role to be? Is this considered to be more of Utilization Review or Quality Assurance? I mean, to just ask patients if their needs were meant seems to be, well, silly, if this is all they expect her to do. It seems that they are using her to create something, but what?? I think she should probably look at the admitting diagnosis and care plans to see of the needs are met, and also have a check list of standard information necessary to further gather resources for the patients that need.

    Is anyone a Discharge Planner in a facility? If so, what do you actually do? Is there a generic form around that can be followed?
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  4. 1
    discharge planning... my favorite subject!
    my staff just helped transition 130 patients from facilities to homecare today....


    check out:

    hospital discharge planning:



    [color=#ffffff]from: root causes
    ensuring care recipient safety along the continuum of care

    jcaho expectations

    below are summaries of continuum of care standards from the camac,

    cambhc, camhc, camh, and camltc. not all summaries below apply
    to all programs. (refer to each manual for the complete standards and
    intent statements and setting-specific language.

    cc.1 within its capability, the organization has a process to provide
    access to the appropriate level of care and services based on the care
    recipient’s assessed needs.

    cc.2 a care recipient is accepted to appropriate care and services based
    on the organization’s assessment procedures.

    cc.2.1 criteria define the information necessary to determine the appropriate care, service, and setting.

    cc.3 the organization provides for continuity over time among the care
    and services provided to a care recipient.

    cc.3.1 the organization provides for coordination of care and services among health professionals and settings.

    cc.4 referral, transfer, discontinuation of services, or discharge of a
    care recipient to another level of care, health professional, or setting is
    based on the care recipient’s assessed needs and each organization’s

    capability to provide needed care and services.

    cc.4.1 the follow-up process provides for continuing care based on the
    care recipient’s needs.

    cc.4.1.1 the care recipient is informed in a timely manner of the need
    for planning for discharge or transfer to another organization or level of
    care.

    cc.5 appropriate information related to the care and services provided is
    exchanged when a care recipient is accepted, referred, or transferred; when his or her services are discontinued; or when he or she is discharged
    to receive further care or services.

    cc.6 an established procedure(s) is used to resolve denial-of-care conflicts.

    when care or services are subject to internal or external review that
    results in denial of care, services, or payment, the hospital makes decisions
    regarding the provision of ongoing care or discharge based on the
    assessed needs of the care recipient.


    additional standards related to continuum of care issues include the
    following:

    pe.1.6 the need for a discharge planning assessment is determined.

    tx.1.1 settings and services required to meet patient care goals are
    identified, planned, and provided, if appropriate.


    pf.3.6 the patient is educated about other available resources and,
    when necessary, how to obtain further care, services, or treatment to
    meet his or her identified needs.

    pf.3.9 discharge instructions are given to the patient and those responsible for providing continuing care.







    from reading your description and shaking my healthcare/homecare crystal ball, what you friend is being asked to do is to evaluate the discharge planning process already provided to patients.

    i would have expected facility to provide her with itemized tool they purchased or devised themselves with following type questions to meet jcaho standards that discharge planning process in facility is evaluated and found to meet most patients needs, problems in current discharge planning process identified and remedied.



    1. staff followed discharge planning policies and procedures. (go check the manual for p+p). yes no na
    2 . was discharge planning provided to patient?
    (chart review/ patient interview) yes no na
    3. was discharge planning multidisciplinary? yes no na
    4. was patient involved in discharge planning process. yes no na
    5. does patient understand plans made to transition to next level of care? yes no na
    6. how prepared does the patient feel to leave the hospital?
    fully prepared little prepared not prepared to leave
    6 a. if not prepared to leave, was patient informed of insurance or medicare hospital discharge dispute mechanism and provided with notice of non-coverage? yes no na
    7. was instruction given by facility staff on discharge medications, treatments and followup care needs/appointments and patient provided with written discharge list? yes no na
    8. does the patient understand the discharge medication schedule? yes no na
    9. was patient given medication and supply equipment prescriptions? yes no na
    10. what kind of home care or follow-up services are set in place? list name of service, otherwise write "na"
    • home health care agency:_________________
    • medical equipment company:_______________
    • assisted living/ skilled nursing/ rehab facility name:____________
    • office of aging referral:________________
    • protective services referral:______________
    • information provided for: meals on wheels, private duty agencies: homemaker/companions, transportation services, medication assistance programs other:_________________
    11. is patient satisfied with discharge planning provided? yes no na
    if no, list items patient concerned about:

    12. how quickly is the discharge process executed?
    list time frame:____________________________

    13. did followup provider admit patient to care? yes no na

    14. did discharge plan meet patient needs upon interview and chart review? yes no na

    comment section should be listed next to each line item to document issue and resolution if needed.
    any significant problems should be addressed pronto.
    report summarized weekly re # discharges reviewed and group issues/problems noted.

    good luck!
    pagandeva2000 likes this.
  5. 0
    Thank you so much! That seems to be exactly what she is required to do, but was no name or criteria to the project. If it is okay with you, I plan to forward this to her. I figured that she needed a check off sheet of some sort to follow. She is my 'bestest friend in the whole wide world' and would do anything to assist her as she has done me. Love to you!
  6. 0
    more funreading:

    discharge planning for the older adult.
    guideline objective(s)
    • to describe assessment parameters for discharge planning in each of the following: functional status, cognition, depression, and caregiver support
    • to identify the elderly most at risk for poor postdischarge outcomes
    • to define specific care interventions for effective discharge planning
    • to discuss potential outcome measurements for comprehensive discharge planning
    discharge planning
    this article focuses on discharge planning across several care settings, each with its own legal framework it gives particular attention to the acute care

    discharge planning for the geriatric patient: pearls and pitfalls

    uthcpc procedures - discharge plan elements

    discharge planning: best practices can result in better customer ...

    discharge planning guide: tools for compliance - google books result
  7. 0
    How can one do a "Project" with no name or criteria???? What a waist of time and manpower!!

    Make sure she speaks to "Project Head" to make sure manager didn't miss meeting/email with project outline and criteria before she develops own tool... feel free to use info above and adapt based on facilities P+P.

    Have friend contact me as on several committees with a hospital Case Mgmt/ discharge planning director that I can contact.
  8. 0
    I will. I tried to tell her for several months about the wonderful resources here at allnurses. She is appreciative, but is not a computer gossiper or lurker like I am. I do plan to forward this information to her, and tell her to join the site, I mean, she can join for free! I thank you, I thank you, I thank you!!!!
  9. 0
    Quote from NRSKarenRN
    How can one do a "Project" with no name or criteria???? What a waist of time and manpower!!

    Make sure she speaks to "Project Head" to make sure manager didn't miss meeting/email with project outline and criteria before she develops own tool... feel free to use info above and adapt based on facilities P+P.

    Have friend contact me as on several committees with a hospital Case Mgmt/ discharge planning director that I can contact.

    But, to answer your question about doing a project with no name or criteria, that is the name of the game at my place of work. Just pick something to do as a hobby and assign someone to it. My friend is a smart cookie, though, and will use the resources provided here and I'm sure elsewhere. She is a great RN who wishes for positive outcomes. She cares deeply about anything she is assigned to do, and I have faith in her; just not where we work...
  10. 2
    discharge planning will consist of many documentation opportunities. it is a catch all for what the nurses on the floor fail to do...so your job will always be added upon. but remember, you are to assist the nurses on the floor, not do their job when it comes to discharging a patient. discharge planning should be started the day a patient is admitted by the floor nurse.

    one of the most important things on a medical record is the medicare form im-cms, where the business office is generally responsible for getting this form signed and dated up-front. this form has to be signed and dated by the patient at the time of inpatient admit and within 2 calendar days of the day of admission,hospitals must issue the im and obtain the signature of the medicare beneficiary or his or her representative to indicate that he/she received and understood the notice. as soon as possible prior to discharge, but no more than 2 days before discharge, the im, or a follow-up copy of the signed im, must also be provided to each medicare beneficiary. the floor nurse should do this because they will have a better clue as to when the patient will be discharged. but you will probably be responsible to over see this form is complete and on the chart.

    if this is not done, and found upon cms audit, your hospital will not be paid for that admission.....

    your job will turn into outcomes management which is another term for case management, social work, utilization management and discharge planning, compliance for several private insurance companies (each with their own rules), plus medicare and medicaid that is unique to each state all rolled into one job. good luck! then staff members will wonder how you got such an easy job. if they only knew the responsibility you have.....
    Last edit by ASSEDO on Jun 21, '08
    NRSKarenRN and pagandeva2000 like this.
  11. 0
    Quote from smithbc1
    discharge planning will consist of many documentation opportunities. it is a catch all for what the nurses on the floor fail to do...so your job will always be added upon. but remember, you are to assist the nurses on the floor, not do their job when it comes to discharging a patient. discharge planning should be started the day a patient is admitted by the floor nurse.

    one of the most important things on a medical record is the medicare form im-cms, where the business office is generally responsible for getting this form signed and dated up-front. this form has to be signed and dated by the patient at the time of inpatient admit and within 2 calendar days of the day of admission,hospitals must issue the im and obtain the signature of the medicare beneficiary or his or her representative to indicate that he/she received and understood the notice. as soon as possible prior to discharge, but no more than 2 days before discharge, the im, or a follow-up copy of the signed im, must also be provided to each medicare beneficiary. the floor nurse should do this because they will have a better clue as to when the patient will be discharged. but you will probably be responsible to over see this form is complete and on the chart.

    if this is not done, and found upon cms audit, your hospital will not be paid for that admission.....

    your job will turn into outcomes management which is another term for case management, social work, utilization management and discharge planning, compliance for several private insurance companies (each with their own rules), plus medicare and medicaid that is unique to each state all rolled into one job. good luck! then staff members will wonder how you got such an easy job. if they only knew the responsibility you have.....
    thank you. it is not me, but my best friend. not sure if they would have an lpn doing this, anyhow. but, i was concerned about her because they gave her such a vague discription of what they wanted done that i wanted to assist her as much as possible to get a framework on what to do. greatly appreciated!!


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