Creating a Discharge Planning Process

Discharge planning is a process within a profession rather than a profession in itself. Because a variety of professionals can perform discharge planning, the process must be structured consistently. Understanding how the process works is necessary to comply with the rules and regulations related to discharge planning. Most relevant legislation makes sense when put in context. Discharge planning is a process that provides a systematic basis for preparing a patient for discharge. It is a dynamic process because of the changing clinical status of the patient and changes in the healthcare system. It is a process that can be used for consistent practice that meets regulatory and accrediting standards and is good for patients and the hospitals that serve their needs.

The first step in the dynamic discharge planning process is the initial assessment. In this step, all patients are assessed so care providers can identify patients who would benefit from discharge planning interventions. This step applies to all patients who are admitted for care in a facility, including a short-term care hospital, inpatient rehabilitation facility, long-term care hospital, or critical access hospital. In the proposed revisions for the CoPs, this and all other steps also apply to outpatients. All patients need a discharge plan, but not all patients experience discharge planning problems. Therefore, the initial assessment should identify which patients need to safely transition to the next level of care, and patients who, without discharge planning services, likely will suffer adverse consequences after discharge. The initial assessment is also used to identify those patients who have known risk factors and who need further intervention to avoid delaying discharge.

Screening is performed for all patients. It determines whether they fit into established screening criteria. The initial assessment of patients may be done by using established criteria that indicate a specific high risk and developing a method of identifying patients who meet them. Each medical specialty, such as orthopedics, cardiology, or pediatrics, should identify criteria that constitute high risk for discharge planning needs. Some high-risk tools apply to all patients, such as risk for unplanned readmission.

For more information, see Discharge Planning Guide: Tools for Compliance, Fourth Edition.