Director’s Desk: The six steps of discharge planning

Editor’s note: The following is an excerpt from HCPro’s Discharge Planning Guide: Tools for Compliance, Fourth Edition, written by Jackie Birmingham, RN, BSN, MS, CMAC. The book discusses issues related to discharge planning from case management’s role as well as various legislative and regulatory initiatives that make getting discharge planning right more important than ever.

Discharge planning, which is integral to providing continuity of care, is a dynamic process in which the goals are to:

• Assess patient needs
• Identify the resources necessary to meet those needs
• Establish and implement plans to meet those needs
• Transition the patient to the most appropriate level of care

The steps make this process dynamic—they sometimes occur in order, they sometimes overlap, and they sometimes move back and forth.

The patient-centered process of discharge planning consists of six dynamic steps (see the figure below for more information):

1. Initial assessment: identifying the discharge needs of all patients and those in need of specialized discharge planning
2. Evaluation of the patient’s continuity-of-care needs, sometimes called transition needs assessment
3. Assessment of post-discharge resources: those resources available to the individual patient
4. Problem identification/goal setting
5. Planning
6. Implementation (discharge, transfer, or referral)

Monitoring is part of the dynamic nature of discharge planning. It should occur throughout the discharge planning process to ensure that the plan accounts for the patient’s progress or lack thereof.