"Our RN attends
discharge planning meetings whenever possible," says Sam Cross, founder of Broad Street Home Care Services in Wilmette.
The first column provides care expectations for the patient with pneumonia, including education, activities, and beginning
discharge planning. The next two columns reflect ongoing hospital care and therapy with instructions for the patient; these include patient-dependent and independent activities.
To make this tool clinically useful for guiding early
discharge planning, patients were divided into minimal-risk (<0.4%), low-risk (0.4-1.5%), moderate-risk (1.5-5.0%), and high-risk (>5% STTGMA score) patients.
CMS has suggested that nurses could help with
discharge planning, but many hospitals face a nursing shortage, the hospital social worker says.
These numbers do not reflect those already engaged in
discharge planning services or who have attended a
discharge planning orientation class.
Among the many strategies for better
discharge planning are programs such as BOOST, developed by the Society of Hospital Medicine, and Project RED, designed by Boston University.
But aside from
discharge planning, there are also "hidden" factors such as how local patterns of hospital use affect readmission rates.
Discharge planning may be perceived by some as the more functional, less rewarding aspect of delivering patient-centred care, but I would challenge this perspective.
Hospital
discharge planning is the primary vehicle for managing care transitions from the hospital to the next setting.
Nurses working in
discharge planning assist these clients to understand and move successfully along the continuum of care.
Speech-language pathologist Ashley (Centre for Neuro Skills, post-acute brain injury rehabilitation programs in California and Texas) introduces chapters with illustrations and case examples spanning the neurologic examination of the patient with TBI and principles of rehabilitation interventions, to
discharge planning and continuing case management.
Discharge Planning RED (Readiness Early Disposition) Plan: Promotes patient clinical and emotional readiness for progression to appropriate level of care.
