Discharge Planning Essay

Improving the quality of discharge planning in acute care include addressing the lack of appropriate staff and patient education about appropriate planning for discharge (4). This includes implementing proper discharge teaching regarding signs and symptoms to seek medical attention, management and care of medical equipment, and access to community resources (4, 5). Other challenges are patients with complex comorbidities too difficult to discharge as well as lack of community supports and equipment for newly discharge patients and lack of rehabilitation and nursing home beds (4). Consequently, acute care units are pressured to vacate hospital beds in response to the growing elderly population. Hospital professionals tend to focus discharge teaching and preparation on medical areas such as diet, activity, treatments, and medications (5). Community referrals to appropriate services at the time of hospital discharge does not often happen contributing to poorer patient outcomes and re-hospitalizations

The overall process of discharging a patient from a hospital and the transition back home or to a care facility are critical advancements in the overall course of both acute and long-term care. It is important that the hospitals releasing these patients have ensured the proper overall course of care from beginning to end. The lack of consistency with both the discharge process and the quality of discharge planning has led to many avoidable readmissions. To reduce the amount of hospital readmissions, it is imperative that hospitals recognize the need for focused patient care and that programs are being implemented to assist in the care transition.

This week’s reflection paper focuses practice-based evidence and the operation of the theoretical framework of person-in-environment as each relates to discharge planning at UMPC Mercy Detoxification Unit (UPMC-MDU).

However, that is not always possible because their in-network hospital may not have a bed available. I have to make sure that all the outpatient providers are in-network with the insurance as well otherwise it will not be covered by the insurance and the patient will not be able to afford the cost of care. I thought having a hospitalist and working closely with the Kaiser case manager to address discharge planning needs helped maintain care quality and contain the cost of care. Successful discharge planning that reduces readmissions are high priority issues addressed in the healthcare reform agenda because it affects both quality and cost of care (Weiss et al., 2015). Weiss et al. (2015) also stated that "...hospitalized patients, regardless of risk status or the setting to which they are being discharged, require some

This model reimburses hospitals based on quality of care instead of the volume of patients. The quality of care is assessed by patient questionnaires and if hospitals are unsatisfactory penalties may be imposed (Edwoldt, 2012). The value-based system also affects Medicare and Medicaid. It was reported that Medicare readmissions within 30 days of discharge cost 17 billion dollars annually (Edwoldt, 2012). Due to the high costs of readmissions Medicare and Medicaid have implemented a Hospital Readmission Reduction program. A formula is utilized to evaluate readmission rates within 30 days of discharge for any medical reason related to their original admission such as heart failure and pneumonia. Upon review the hospital is potentially penalized. It is important that nurses strive to provide excellence in care despite their beliefs on the ACA. Nurses have the ability to provide a safe patient environment and reduce the risk of hospital associated infections by following hospital protocols such as hand washing.

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

Hospital discharge has been defined as “a systemic problem that can be characterized as a dangerous situation in which latent conditions exist such that sharp end individuals are set up to fail” (Anthony et al., 2005). Understanding this process is flawed warrants an investigation for a change in practice. Research has explored a variety of interventions that address reducing 30-day readmissions such as post-discharge phone calls, RED toolkit, BOOST toolkit, transition coaches, and home visits after discharge. Despite these tools, 30-day readmission rates among the older adult population continue to be a challenging issue.

Hospitals started to be penalized by CMS in 2012 for high readmission rates that could add up to one percent of what Medicare paid the hospital. This affected two thirds of all hospitals in the United States. Now, the penalty has gone from one percent to three percent. The purpose was to increase the focus on the discharge process that will lead to better outcomes with a decrease in readmissions (Polster, 2015). The purpose of this post is to discuss two learning objectives that Tina would be able to meet at the end of receiving discharge instruction. With each objective, this post will discuss the content of instruction, method of instruction, rationale for the chosen method, the time allotted for the task, resources needed, evaluation method, evaluation criteria, what specific criteria needs to be achieved for the objective to be met, potential barriers and a plan to deal with these barriers.

As we care for our patients in a hospital settings, our goal is to get them better so that they can be discharged. Most of the time recovery continues at home or at another facility. With shorter stays in the hospital setting, the recovery at home requires increased nursing and caregiver interventions. Based on statistics published by the Center for Medicare and Medicaid Services (CMS), the rate for readmission, within the first 30 days of discharge, in 2012, for Medicare FFS (Fee-for-service) beneficiaries, averaged 18.4 percent (Gerhardt et al., 2013). Throughout this paper, readmission refers to a “return hospitalization to an acute hospital following a prior acute admission within

Good job on your project so far. Management of chronic illnesses is necessary to reduce readmissions. A major contributor of health care cost is high numbers of hospital readmissions, especially for people with chronic illness such as diabetes. Post discharge interventions such as telephone reminders by trained individual who asked patients are they taking their medication? Educating patients about treatment plan, how to detect warning signs, monitoring of blood glucose and self-management (2014).

Health care systems across the world are facing a number of challenges, which include changing patterns of diseases, a shortage of health care professionals, inaccessibility of services, and insufficient resources. Given that an increasing population creates a greater demand for healthcare services, the shortage of hospital beds due to high admission rates and increased length of stay are some of the challenges that the healthcare system of Saudi Arabia is struggling to overcome. The Saudi Arabian government funds 244 hospitals that have a capacity of 33,277 beds (Almalki, Fitzgerald, & Clark, 2011). However, there was a forecast of bed capacity shows that, by 2013, the healthcare system in Saudi Arabia will require about 14,700 additional beds to meet the increasing demand for healthcare services (RNCOS, 2011). The shortage of beds implies that the healthcare system needs to formulate ways of increasing hospital bed capacity. The problem being investigated is the Saudi Arabian hospital bed shortage due to increased length of stay in hospitals by patients with chronic illnesses, the elderly, and the disabled. The purposes of the proposed study are to describe the post-acute care needs and also the need for effective discharge planning.

For years, healthcare costs have continued to increase in the United States and policymakers are constantly trying to find ways to reduce spending. According to reports, in 2011, about $900 billion out of the $2.6 trillion annual health care spending was wasteful spending. In the following year, there was a reported $690 billion wasted annually on healthcare. This wasteful spending is attributed to ineffective health care delivery, cost of adverse events, and poor care coordination that has led to avoidable readmissions (Lallemand, 2012). In the United States, readmissions are the highest amongst patients with chronic diseases accounting for about 90% of avoidable readmissions in 30 days after discharge, and costing the industry an estimated $17 billion. These readmissions are a result of inadequate discharge planning, lack of follow-up, and lack of education on disease management (Jayakody et al., 2016). Policymakers on the federal and state level have developed and implemented several programs, some varying state to state, to help reduce wasteful spending while improving quality of care.

Health Care systems around the world are undergoing changes. One major area of change for the United States is Emergency readmissions within 30 days of discharge form hospitals. This indicator looks at the overall percentage of inpatient admissions of patients who returned to a hospital as an emergency visit within 30 days of the leaving the hospital stay. This indicator measures rate of success of the organization in helping patient recover effectively from injuries or illnesses. If the organization does not meet the standards for readmission set forth by Medicare they will face with readmissions penalties. Readmission penalties are a reduction of payment for inpatient services for Medicare patients.

Cost is always a great way to persuade stakeholders, and some of the literature discusses the financial impact of readmission. It was found in one study that due to the intervention of follow-up phone calls, the cost savings of readmissions within thirty days was reduced by $1.4 million dollars (Harrison, Hara, Pop, Young, & Rula, 2011). In the new nursing culture, it is important to offer patient-centered care, and the intervention of discharge phone calls does just that. Each article discusses the quality of effective communication and how this improves patient satisfaction surveys and overall

Discharge planning and management with an elderly person can become very complicated and should be approached with an open mind and the willingness