Discharge Planning
Posted by admin on November 18th, 2009Hospital discharge must be carefully planned and appropriately insti¬tuted. A social worker or discharge planning coordinator should he in¬volved in discharge planning, and the consultation should begin soon after admission. Such early involvement by social services personnel may shorten the length of slay and prevent the need for nursing home placement. Early planning is also needed so that equipment, such as a hospital bed or oxygen, can be delivered to the patient’s home and ar¬rangements for home nursing care can be made. When nursing home admission is considered, a geriatrician should perform a thorough eval¬uation.
Patients being discharged to their homes need detailed instructions about follow-up care, and family members or other caregivers must be trained lo provide it. Failure to teach them how to use medications, implement treatment, and monitor recovery increases the likelihood of adverse outcomes and readmission. Follow-up appointments and medi¬cation schedules should be written down for she palient and family. A copy of a brief discharge summary plan should be given lo the patient or family in case questions arise about care before the official summary plan is sent lo the primary care physician.
When patients are discharged to a nursing home or another hospital, communication is especially important. A’written summary should be sent with the patient. This summary should include not only the stan¬dard medical information hul also a summary of mental and functional status, the limes Ihe patient last received medications, known drug al¬lergies, advance medical directives, and family contacts. Optimally, a nurse should call the receiving institution to review such information shortly before the palient is transferred.
