Best practices in discharge planning

1. Best practices in discharge planning The Medical City Good Hospital Practice training series 2009

2. Outline of presentation • Why plan for discharge • The twin goals of discharge planning • The roles of the Attending Physician, residents and staff in discharge planning • The components of discharge planning • Discharge planning for acute and chronic care patients

3. Why plan for discharge? • The act of leaving a hospital constitutes a ‘gap’ or interruption in care delivery where information can be lost and risky discontinuities arise. • Which medicines do I take? • Which home medicines do I resume? • Anong pagkain ang bawal? • How do I take my BP? • Can I drive?

4. Why plan for discharge? • An elderly lady with pneumonia is discharged from the hospital only to return after a few hours. She suffered a heart attack on the way home. • A patient who underwent prostate surgery was re-admitted after 2 days for severe hypogastric pain and difficulty in urination. • A 24 year old female consulted at the ER for dizziness and palpitations. Two days ago, she was discharged after being treated for diarrhea but began taking Lomotil when her watery stools persisted.

5. Why plan for discharge? • Our responsibility towards our patients does not end upon their discharge. We have the duty to ensure that their care is seamlessly continued at home and in other places. Welcome home, Lolo!

6. Why plan for discharge? • To safely discharge patients, we must endorse our responsibility in caring for the patient to other professionals or organizations in our patients’ communities.

7. Why plan for discharge? • Because our patients need to get out of their sick roles. • Our patients need to re-imagine themselves as whole, self-sufficient and satisfied people again. • They need wellness goals to aim for, mental images to sustain their recovery efforts.

8. The twin goals of discharge planning • Patients are discharged in an efficient, safe, timely and coordinated way based on clear achievement of collaboratively developed goals. • Though separated from the hospital, coordinated patient care is continued and maintained by the hospital and community providers to ensure optimum rehabilitation and / or recovery.

9. The role of the Attending Physician in discharge planning The AP is responsible for planning and coordinating the discharge process. APs must ensure that a relevant pathway is activated daily if appropriate. A pathway facilitates care planning and discharge planning

10. The role of the Attending Physician in discharge planning The AP is responsible for planning and coordinating the discharge process. APs must review variances from expected outcomes daily and modify care accordingly. This promotes timely interventions. It also alerts the team if the expected LOS cannot be achieved.

11. The role of the Attending Physician in discharge planning The AP is responsible for planning and coordinating the discharge process. Upon admission, APs must begin educating their patients / family about their expected LOS and expected outcomes of care. APs must ensure that the discharge summary is begun upon admission.

12. The role of the Attending Physician in discharge planning The AP is responsible for planning and coordinating the discharge process. APs must ensure that all Referred Physicians • sign off as soon as their management roles are finished. • clear the patient for discharge as soon as they sign off. AP

13. The role of the residents and nurses in discharge planning The residents and nurses must review care outcomes daily and alert the AP for any variances that can extend the expected LOS. Residents and nurses must work together to conduct daily reviews and revise appropriately • Any activated pathway • The nursing care plan

14. Discharge planning begins on admission • Anticipate your patients’ discharge needs. • We can prepare their discharge summaries ahead of time. • Anticipate your patients’ length of stay (LOS) • We can tell patients their expected LOS and ensure that discharge criteria are achieved within the expected LOS.

15. Discharge planning begins on admission Provide for your patients’ discharge needs while they are still in the hospital. • We can begin training our patients to take care of themselves and their families to address their health needs after discharge. • We can point them to the appropriate community resources that can address some of their health needs.

16. Discharge planning occurs throughout confinement • Preventable adverse events following discharge are almost always related to issues of communication. • The most frequent adverse events following discharge involve the use of medication. • When patients do not clearly understand how to take their medications, or how their medications and their diet can interact, adverse drug events can occur.

17. Medication reconciliation is part of discharge planning APs must reconcile meds taken before admission with meds ordered upon admission. APs must reconcile meds to be taken following discharge with meds given during confinement and meds taken before confinement. Failure to do so leads to medication confusion, poor patient compliance and adverse drug reactions.

18. Patient education is part of discharge planning 1st hospital day round 2nd hospital day round 3rd hospital day round 4th hospital day round When you round your patients, teach them about • Their condition, treatments and outlook • Safe use of medications • Diet and nutrition • Self-care • Rehabilitation techniques • Safe use of devices and equipment • Pain relief • Mental health and social well being • How to get reliable health information • Financing costs of care IMPORTANT: Document your teaching on Interdisciplinaty Patient and Family Education Record (IPFER).

19. Communication after discharge For good post discharge care, three types of communication are required: 1. Communication between hospital and patient: diagnoses and treatments, follow-up plans, symptoms that should prompt action, and who to contact if things don’t go according to plan 2. Communication between hospital and community providers who will be providing ongoing care to the patient. 3. Communication between patient and a responsible clinician if things are not going according to plan after discharge.

20. What are the components of discharge planning? • Providing evidence-based INFORMATION to your patients • Titrate the amount and content of information against your patient’s educational readiness and ability. • Ensuring your patient’s UNDERSTANDING • Challenge your patient to paraphrase and demonstrate mastery of your educational messages. • Reaffirming your THERAPEUTIC ALLIANCE with your patient. • Constantly validate your patient’s / family’s abilities to care for themselves and your continuing readiness to support their efforts. Both of you are in this together as partners!

21. Discharge planning is mostly easy! Most TMC patients are confined for acute care and need only basic discharge planning. In general, acute care patients need to know how to • Avoid getting sick again • Take their medications and when • Modify their diet if needed • Resume normal activities and when • Call for medical help if needed and whom • Go for a follow-up visit and when

22. Discharge planning is mostly easy! For example, patients with uncomplicated acute infections need to know • Basic hygiene practices to avoid repeated exposure to pathogens • Doses, frequencies and durations of all home medications • Diet modifications for recovering GI tract • Safety and activity modifications • The telephone number to reach their AP • The date, time and place of their follow-up visit

23. Discharge planning is more challenging in some patients Patients with conditions such as these need ongoing care and are at highest risk for adverse events following discharge. • Acute myocardial infarction • Chronic renal failure • Congestive heart failure • Hip fractures • Stroke • Complicated diabetes • Complicated hypertension • Severe asthma • Severe pneumonia • Chronic lung disease Other patients who need detailed discharge planning include patients with cancer or recurrent serious diseases and those who underwent major debilitating surgery.

24. What information is provided when planning for discharge? • Their condition, treatments and outlook • Safe use of medications • Diet and nutrition • Self-care • Rehabilitation techniques • Safe use of devices and equipment • Pain relief • Mental health and social well being • How to get reliable health information • Financing costs of care PLUS • How to call for medical help if needed • How to go for a follow-up visit and when

25. Discharge planning for post stroke patients may include… • The nature, treatment and prognosis of stroke • Doses, frequency and durations of all medications • Dietary modifications to reduce stroke risk • Self-care, safety precautions and home activities • Physical therapy modalities • Safe use of wheelchairs, crutches, tracheostomy, etc • Bed sore care • Psychosocial therapy and integration • Stroke support groups, community rehab centers • Patient education resources in the Web PLUS • How to call for medical help if needed • How to go for a follow-up visit and when

26. What are some resources that we can help our patients gain access? • Community hospitals • Community ambulatory facilities • Private health care practitioners • Patient support groups • Non-government organizations involved in health education and advocacy • Charities and philanthropic institutions • Radio, TV and print materials • Internet • TMC patient education flyers and lay fora

27. How do we help our patients gain access to these resources? • We can provide our patients with referral letters to specific community practitioners. • We can refer in writing our patients to patient support groups. • We can endorse in writing our patients to non-government organizations. • We can provide our patients with lists of radio, TV and print materials and Internet resources. • We can provide our patients TMC patient education flyers and enroll them in TMC lay fora.

28. Discharge planning is about going the extra mile for patients Let’s face it. Discharge planning is not yet in our culture of hospital care. But one day, when we or our loved ones become patients, we will appreciate the extra efforts of our physicians and nurses to make sure we stay safe and connected to the hospital while recovering in our homes.

29. Summary of presentation • Planning for discharge promotes efficient, safe, timely and coordinated separation of patients from the hospital while ensuring that patients are effectively handed over to community health care providers. • Discharge planning begins upon admission and continues throughout confinement. • The Attending Physician leads the health care team in discharge planning. • Information, understanding and therapeutic alliance are essential components of discharge planning • Discharge planning for chronic care patients anticipates many health care needs and helps patients gain access to community health care resources.

30. Are you an effective discharge planner? 1. Planning for discharge must begin On the day of discharge 24 hours before discharge 48 hours before discharge On the day of admission Answer: d. Discharge planning must begin on admission. You can start writing the Discharge Summary.

31. Are you an effective discharge planner? 2. Planning and coordinating an effective discharge process is the ultimate responsibility of the • Nurses • Residents • Attending Physician • The Medical City Answer: C.

32. Are you an effective discharge planner? 3. Attending physicians can plan for discharge during admission by • Activating the relevant pathway • Reconciling medications before and after admission • Informing the patient of the expected LOS • All of the above Answer: D

33. Are you an effective discharge planner? 4. The components of discharge planning include the following EXCEPT • Providing evidence-based information to the patient • Ensuring the patient’s understanding • Establishing rapport and trust with patient and family • Reaffirming therapeutic alliance with the patient Answer: C

34. Are you an effective discharge planner? 5. Discharge planning for post surgical patients include • Safe wound care • Resumption of normal diet and physical activity • Credible Websites on patient’s condition • All of the above Answer: D

35. Are you an effective discharge planner? • 6. A 72 year old female from Iloilo is admitted for pneumonia and PTB today. As her AP, you can plan for her discharge today by • Reviewing her medications before confinement and reconciling these with the medications you ordered. • Briefing the entire health care team of the care plan, her expected length of stay and expected outcomes of care • Educating her on the cause and guideline-based treatment of her PTB and pneumonia. • All of the above • Answer: • D

36. Are you an effective discharge planner? • 7. Today is her 3rd day of confinement. Her fever and cough persists. To plan for her discharge, you can • Review care plans and check if other care outcomes are being met. Look for signs that can extend LOS. • Check her compliance to oral medicines, both before and during confinement. Is she able to take many drugs? • Ask her and her family to demonstrate taught chest physiotherapy. Poor lung toilet can retard recovery. • All of the above • Answer: • D

37. Are you an effective discharge planner? • 8. Today is her discharge day. To ensure safe discharge, you will • Ask her to come back 2 days from now for close follow-up. • Insist that she follows up with The Medical City TB DOTS clinic to ensure compliance. • Give her and her family a phone number to promptly reach you should she feel the need. • All of the above • Answer: • C

38. Are you an effective discharge planner? 8 out of 8 – patient-centered champion! 6 or 7 out of 8 – getting there 4 or 5 out of 8 – just about barely 2 or 3 out of 8 – you can clinch it next time!* 0 or 1 out of 8 – let us try again* * Please go over the slides again.

39. Discharge planning at The Medical City Because failing to plan is planning to fail!

40. This SIM Card certifies that______(please overwrite with your name, thank you)__,MDhas successfully completed the Self Instructional Module on Discharge Planning.(Sgd) Dr Alfredo Bengzon (Sgd) Dr Jose AcuinPresident and CEO Director, Medical Quality Improvement