Discharge Clinic Case Study

Discharge planning is used to create a plan of care for a patient who is leaving a care setting. An evaluation is done to determine the patient’s continuing care needs once they have left the care facility. When patients are send back home or to a facility that does not require full time nursing care assistance, programs need to be put into place to ensure that the patient is receiving the proper continuation of care post discharge. Proper discharge planning can decrease the chances of a hospital readmit, help in recovery, ensure medications are prescribed and given correctly, and adequately prepare family or caregivers to assume proper post discharge care. According to the Family Caregiver Alliance, “It is important, not only for patients, but family

The office would need to establish a goal to accommodate all post-discharge patients. When appointments cannot be made then an escalation process to the office manager needs to occur. In order to foster communication with professional partners, an investigation of the system failures. How can the transition to home be improved? The workflow should include a validation step that would entail hand-off communication between hospital rounders and office schedulers. If missteps occur, then the office staff could catch the near misses and call the patient at home. Care coordination among providers on an outpatient basis could be supported by the electronic medical record and having verbal care conferences. Next strategy could involve the hospital completing a call back within twenty-four hours to all patients discharged. This intervention could potentially catch some of the missed opportunities. Another approach involves face to face reinforcement of the patient-centered partnership with H. H. According to Counsil et al. (2012), “patient-centered care plans for complex patients changed the relationships with the health team” (p. 190). The development of this patient directed plan of care and partnership is

Discharge planning is a routine feature of health in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmissions to hospital, to improve the co-ordination of services following discharge from hospital thereby bridging the gap between the hospital and community (S. Shapperd, 2008). The focus of this story is discharge planning that occurs while

In December 2015, The Joint Commission launched a campaign seeking to reduce readmissions by providing resources for both health care providers and patients to engage patients in the discharge planning process.1,2 According to voluntarily reported data collected by The Joint Commission between January 2014 and October 2015, the major contributors to 197 sentinel events were failures in patient communication, patient education, and patient rights.2 A review of communication during the hospital discharge process found that discharge summaries often lacked information on counseling, treatments, discharge medications, test results, and follow-up plans.3

Zakzesky, Klink, McAndrew, Schroeter, and Johnson (2015) used a qualitative, descriptive survey to study the discharge process, including MDR from the patient’s point of view. A convenience sample of 14 participants from a

Early identification of these patients helps to identify individual patient needs and problems so that coordinated efforts can be utilized to meet the patient’s needs. Failure to coordinate care, gaps in inpatient treatment and therapy along with lack of proper patient care follow up post discharge increases the chance of readmission for these patients (Chamberlain, Lau, Siracuse,

The Robert Wood Johnson Foundation (2013) reports, “The U.S. healthcare system suffers from a chronic malady—the revolving door syndrome at its hospitals.” Currently, one of the many challenges hospitals face are increasing readmission rates. Various factors could contribute to the issue at hand. In this paper, the effectiveness of discharge planning will be explored to compare the efficiency of actual practice versus evidence-based practice research.

The main role of the position is to provide clients with resources to have a safe and successful discharge. The essential duties of a discharge planner is to meet with an interdisciplinary team each morning to discuss the long length of stays, which clients will be discharging that day and whether home is a safe option. Some challenges discharge planners face that correlate with social issues are, clients

St. John’s Regional Medical Center and Community Memorial Health System (CMH) are two very important stakeholders for the discharge navigator project, so we brought them on board during the early stages of the

What does the literature show? A search of the literature has identified various risk factors and proposed best practices to decrease readmission rates to hospitals. A retrospective observational study that looked at the effect of a transition of care clinic (TOC) model on the 30-day rehospitalization rate in a single medical center found that patients who attended the TOC clinic had a significantly lower 30-day readmission rates (3.8% versus 11.7%) compared to those who did not (Hudali, Robinson & Bhattarai, 2017). The discharge planning should begin on

In a quarter of the hospitals, about 25% of the admissions are rehospitalizations that occur within 30 days after discharge (Jencks). There are a number of factors that contribute to avoidable hospital readmissions. Some of these reasons include: poor quality and transition of care between different providers and care setting, discharging of patients prematurely, discharging patient without providing adequate information of their care and the lack of coordination with information of patients between inpatient and community-based providers.

The recommendations of the RED guideline are easily identifiable, prominent, and specific to the overall purpose of reducing unplanned readmissions within 30 days after a patient has been discharged. Alternative actions to support these recommendations have been unfolded as well. For instance, the RED Toolkit states that where a patient does not understand the discharge plan, the caregivers should interview him or her further to see if there is any other person, such as a family member or friend, who could be informed about it on his or her behalf. There were some implementation issues that need to be addressed to make sure that the toolkit can be used in a variety of health care settings and patient populations.

Hospitals and other medical facilities like to keep things moving along efficiently. One tasks that might get out of hand is the discharge summary. This is a summary of the patient's hospital stay. Creating a discharge summary is a difficult tasks for those working in a busy hospital environment. However, the staff at numerous medical facilities discovered that a discharge summary template helped to simplify the entire process. Often, the quality of the summary affects the entire standing of the hospital. Therefore, it is important that the hospital create a professional quality discharge summary that is clear, precise, and complete.

The need to reduce the 30 day mental health readmission rate at St. Luke’s Hospital is not a new idea. St. Luke’s has a departmental goal of reducing the 30 day readmission rate on the mental health unit. The 30 readmission rate is currently 10.2% on 3W. The 3W 30 day readmission rate has been calculated by counting every admission and transfer to the unit for a particular month and dividing it by the list of patients who have been readmitted from that month within 30 days. The 3W readmission rate of 10.2% is higher than the national average of 9% (AHRQ, 2015). The 3W interprofessional team has identified the need to reduce readmission rates. The mental providers are all experienced with many years of practice. Alternatively the registered

Top-performing hospitals begin discharge planning on admission (33), with staff assessing the patient’s risk factors, needs, resources, knowledge, and family support within 8 hours of admission. Most hospitals have quality improvement (QI) projects in place to improve the discharge process, streamline care coordination mechanisms, and encourage patient self-management of chronic diseases. Some facilities have discharge planning nurses or teams that assist with the discharge process. Often patients are instructed to follow up with their primary physicians (GP) within a determined time. It has been recognized that patients readmitted within 30