Conducting Discharge Planning Nursing

Conducting Discharge Planning Nursing

Why This Skill Exists

Discharge planning is a CMS Condition of Participation (§482.43) requiring hospitals to have a discharge planning process that applies to all patients. Effective discharge planning reduces 30-day readmissions — a CMS quality metric under the Hospital Readmissions Reduction Program (HRRP) that imposes payment penalties for excess readmissions for heart failure, acute MI, pneumonia, COPD, THA/TKA, and CABG. The Joint Commission requires a coordinated, patient-centered discharge process. ANA Standard 5 (Implementation) includes coordination of care and Standard 5B includes health teaching as core components. HCAHPS discharge information domains directly affect hospital reimbursement under Value-Based Purchasing. Poor discharge planning contributes to medication errors at transitions (an estimated 60% of medication errors occur at care transitions), patient confusion, missed follow-up, and preventable readmissions.

Checkpoint A — Intake Verification

Required Patient Information

• Current medical diagnoses and problem list
• Current functional status: mobility, ADL independence, cognitive function
• Discharge disposition: home, home with services, SNF, LTACH, inpatient rehab, hospice
• Social determinants of health: housing stability, transportation access, food security, caregiver availability, insurance status
• Patient/family goals and preferences for post-discharge care
• Advance directives and code status (relevant for skilled nursing or hospice transitions)
• Language, literacy, and cultural considerations

Required Clinical Information

• Discharge medication list (reconciled against admission medications)
• Pending diagnostic results that may affect discharge plan
• Outstanding consults or procedures
• Activity restrictions and weight-bearing status
• Dietary restrictions or requirements
• Wound care or ongoing treatment needs
• DME (durable medical equipment) requirements
• Follow-up appointment requirements (PCP, specialist, surgeon)

Screening for Post-Discharge Risk

• LACE Index score or institutional readmission risk tool completed (Length of stay, Acuity of admission, Comorbidities, Emergency department visits in prior 6 months)
• High-risk medication regimen identified (anticoagulants, insulin, opioids, immunosuppressants)
• History of prior 30-day readmission
• Lives alone or has inadequate social support
• Three or more active comorbidities

Step 1 — Initiate Discharge Planning on Admission

Discharge planning begins at admission per CMS CoP §482.43:

1. Screen all patients within 24 hours of admission for discharge planning needs using institutional screening tool
2. Identify patients requiring formal discharge planning evaluation:
   • Patients with complex medical needs
   • Patients likely needing post-acute services (home health, SNF, rehab)
   • Patients with inadequate social support or housing instability
   • Patients with readmission risk factors
3. Initiate interdisciplinary discharge planning team involvement: case management, social work, physical therapy, occupational therapy, dietitian, pharmacy as appropriate
4. Set an estimated discharge date (EDD) and communicate to patient/family and care team
5. Document the initial discharge planning assessment in the medical record

Step 2 — Conduct Medication Reconciliation for Discharge

1. Compare the current inpatient medication list against the pre-admission medication list
2. Identify medications that were: continued, modified (dose/frequency change), added (new), or discontinued during the hospitalization
3. Resolve discrepancies: For each changed medication, document the clinical rationale
4. Verify the patient/caregiver can obtain all discharge medications:
   • Insurance formulary coverage
   • Pharmacy access
   • Cost barriers (coordinate with social work or pharmacy for patient assistance programs)
5. Generate the discharge medication list in plain language with:
   • Medication name (generic and brand)
   • Purpose
   • Dose, frequency, route
   • Special instructions (take with food, avoid grapefruit, etc.)
   • Common side effects and when to contact provider
6. Highlight high-risk medications requiring additional teaching (anticoagulants, insulin, opioids)

Step 3 — Provide Discharge Education Using Teach-Back

Mandatory education topics per CMS and Joint Commission requirements:

1. Diagnosis understanding: What was wrong, what was done, and current status in plain language
2. Medication review: Review each discharge medication using the reconciled list; use teach-back
3. Activity restrictions: Specific limitations (no lifting > 10 lbs, no driving for 2 weeks, etc.)
4. Diet: Specific dietary requirements or restrictions with written instructions
5. Wound care / ongoing treatments: Demonstrate and have patient/caregiver return-demonstrate
6. Follow-up appointments: Confirm dates, times, locations, provider names; address transportation
7. Warning signs: Specific symptoms requiring emergency care vs. provider contact
   • Use condition-specific red flags (e.g., CHF: weight gain > 2 lbs/day, worsening SOB; surgical: fever > 101.5°F, wound drainage change)
8. Equipment use: Demonstrate any DME (oxygen, glucometer, wound vac, etc.)

Document teach-back results for each topic. Reference managing-patient-education skill for detailed teaching methodology.

Step 4 — Coordinate Post-Discharge Services

1. Home health referral: Submit orders for skilled nursing, physical therapy, occupational therapy, speech therapy, home health aide as indicated; ensure referral includes specific visit frequency and duration
2. SNF/LTACH/Rehab placement: Coordinate with case management; ensure medical records transfer; confirm bed availability; arrange transportation
3. DME coordination: Order equipment, confirm delivery date/time, arrange for patient/caregiver training
4. Outpatient services: Schedule follow-up appointments before discharge; PCP follow-up within 7 days (within 48 hours for high-risk patients)
5. Community resources: Connect patient/family with disease-specific support groups, nutrition programs, transportation services, pharmacy assistance programs
6. Caregiver support: Assess caregiver burden; provide caregiver education and respite care resources

Step 5 — Execute Day-of-Discharge Protocol

1. Confirm all discharge orders are complete and signed
2. Verify discharge medication prescriptions are transmitted to pharmacy or provided to patient
3. Perform final medication reconciliation at discharge — compare what patient received inpatient against discharge orders
4. Complete all discharge education with documented teach-back
5. Provide written discharge instructions: medication list, follow-up appointments, activity restrictions, dietary instructions, warning signs, emergency contact numbers
6. Ensure patient has follow-up appointment confirmed (not just "call to schedule")
7. Arrange transportation
8. Remove IV access, urinary catheter, and other devices not needed post-discharge
9. Perform final assessment: vital signs, pain assessment, ambulation status
10. Escort patient to vehicle per institutional policy

Step 6 — Document the Discharge

1. Discharge summary note: date/time, condition at discharge, mode of transport, accompanied by whom
2. Discharge medication list: complete reconciled list with patient/pharmacy copies
3. Discharge instructions: all topics covered with teach-back results documented
4. Follow-up plan: appointment dates, provider names, pending results with follow-up plan
5. Referrals placed: home health, DME, outpatient services with confirmation
6. Patient education: topics covered, materials provided, learner identified, teach-back results
7. Advance directive status: confirmed and communicated to receiving facility if applicable

Checkpoint B — Discharge Readiness Review

Patient Readiness

• Patient/caregiver can verbalize diagnosis, medication regimen, warning signs (teach-back confirmed)
• Patient/caregiver can demonstrate any required skills (wound care, injection, equipment use)
• Patient has transportation arranged
• Patient has medications or prescriptions in hand
• Patient has written discharge instructions in preferred language

System Readiness

• All discharge orders complete and signed
• Medication reconciliation completed with discrepancies resolved
• Follow-up appointments confirmed (not just recommended)
• Home health/SNF referral submitted and confirmed
• DME ordered and delivery confirmed
• Discharge summary dictated/completed for PCP communication
• Transition record sent to receiving provider/facility per CMS requirements

Quality Audit

• Discharge planning initiated within 24 hours of admission per CMS CoP §482.43
• Readmission risk screening completed with appropriate interventions for high-risk patients
• Medication reconciliation performed at discharge with discrepancies resolved and documented
• Teach-back documented for all required discharge education topics
• Follow-up appointments scheduled before discharge (PCP within 7 days for general; 48 hours for high-risk)
• Written discharge instructions provided in patient's preferred language at appropriate literacy level
• Condition-specific warning signs included in written instructions
• HCAHPS discharge information domains addressed: understanding of care at home, understanding of medication purpose
• 30-day readmission rates tracked per CMS HRRP conditions
• Discharge process compliant with CMS CoP §482.43, Joint Commission standards, and ANA Standards 5 and 5B

Guidelines

• CMS CoP §482.43: Hospitals must have a discharge planning process; evaluate patients for discharge needs; develop discharge plans; arrange for post-hospital services
• CMS HRRP: Hospital Readmissions Reduction Program penalizes hospitals with excess 30-day readmissions for specified conditions
• Joint Commission: Transition of care standards require coordinated discharge with patient engagement, medication management, and follow-up
• ANA Standards: Standard 5 (Implementation) includes coordination of care; Standard 5B (Health Teaching) requires education for self-management
• HCAHPS: Discharge information domain questions directly affect hospital reimbursement
• Medication reconciliation: Joint Commission NPSG.03.06.01 requires medication reconciliation at every transition of care
• Health literacy: Discharge instructions must be at or below 6th-grade reading level; use teach-back to verify comprehension
• Scope of practice: RN coordinates discharge planning, performs medication reconciliation, delivers and evaluates discharge education; case management arranges post-acute services; social work addresses psychosocial barriers; pharmacy reviews medication reconciliation for high-risk regimens
• Post-discharge follow-up: Evidence supports follow-up phone calls within 48–72 hours of discharge to reduce readmissions; include medication review, symptom assessment, and appointment confirmation