Q&A: Final Discharge Plans

Q. What categories should a patient’s final discharge plan include?

A. The final discharge plan should include the following:

• Plans for collection of further information—Schedule follow-up physician appointments and outpatient diagnostic procedures.
• Plans for intervention necessary for the continuing-care plan—Describe the patient’s, family’s, and postacute care provider’s understanding of how the discharge plan is to be implemented.
• Medication and dietary reconciliation work. Notice the addition of dietary to the reconciliation effort.
• Plans for educating patients about their illness and their role in its management—Explain methods by which patients must monitor their own progress daily (e.g., weight, blood pressure, blood glucose, pain scale) and how they should respond if the trend indicates they should contact their physician. For example, patients with congestive heart failure should know the amount of weight gain and time frame that would trigger a call to their physician. Pay particular attention to medication and dietary plans and restrictions during the period after discharge.
• Discharge instructions for patients being discharged to home without a referral are now a part of the Medicare Conditions of Participation for discharge planning. Therefore, it is important from not only a patient perspective, but from a compliance perspective to include what instructions were given to the patient regarding their post-discharge needs.

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

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