Discharge Planning Requirements at a Glance
What Hospitals Should Consider in Evaluating a Patient’s Discharge Needs
• Presenting diagnosis or patient’s reason for coming to the hospital.
• Relevant comorbidities and medical and surgical history.
• Types of physicians involved in the patient’s care after discharge, such as specialists or primary care physicians.
• Location from where patient was admitted.
• Use of community-based services.
• Vital signs including pain level and management strategies.
• Readmission risk.
• Discharge plan from previous hospitalization.
• Relevant psychosocial history.
• Payer status: Medicare, Medicaid, commercial, workers’ compensation, no funding.
• Ability to pay for medications, ordered equipment, special dietary needs.
• Ethnic and cultural beliefs and practices related to healthcare.
• Communication needs including language barriers, diminished eyesight and hearing, and self-reported health literacy challenges of the patient or the patient/s caregiver/support person.
• Patient’s access to non-healthcare services and community-based care providers.
• The patient’s treatment goals and preferences.
• Barriers to the patient’s goals and preferences.
• Alternative options for patient’s goals and preferences.
Discharge Instructions for Patients Being Discharged to Home
Discharge instructions must be provided at the time of discharge to the patient or the patient’s caregiver or support person and the post-acute provider if the patient is referred for post-acute care. They must include, but are not limited to:
• Instruction on post-hospital care as identified in the discharge plan.
• Written information on warning signs and symptoms that may indicate the need to seek immediate medical attention, including who should be called if the warning signs and symptoms exist.
• Information on prescriptions and over-the-counter medications required after discharge including the name (brand name and generic), indication, and dosage of each drug, and any significant risks or side effects of each drug.
• Reconciliation of all discharge medications with medications the patient was taking before discharge.
• Written instructions, either on paper or in electronic format, of follow-up care, appointments, pending or planned diagnostic tests, and contact information including telephone numbers for practitioners involved in follow-up care and any providers or suppliers to whom the patient has been referred.
What to Send to the Receiving Provider at the Time of Transfer
The following information should be sent to post-acute facilities, home health agencies, and other community agencies to which the patient is being transferred. The information should be reviewed by the case managers to determine whether it will be important to the next provider of care.
In addition to a copy of the patient’s discharge instructions, the discharge summary, and other documents to ensure a safe and effective transition in care, the transfer information should include:
• Demographic information including name, gender identity, date of birth, race, ethnicity, and preferred language.
• Contact information for the practitioner responsible for the care of the patient and the patient’s caregiver or support person, including the name, telephone number, and relationship.
• Any advance directives.
• Patient education provided to the patient or caregiver.
• Procedures, including surgical or diagnostic, that the patient received along with the response and outcomes.
• Diagnoses with ICD-10 code if known.
• Infectious disease status at the time of discharge, if applicable.
• Patient’s mental status at the time of discharge.
• Results of laboratory tests and other diagnostic procedures.
• Tests and procedures pending at the time of discharge and how the next provider can access the reports.
• Results of any consultations.
• Functional status assessment including activities of daily living at discharge and projected instrumental activities of daily living.
• Psychosocial assessment and cognitive status.
• Patient’s social support.
• Behavioral health issues. (Verify state rules for communicating this information without the consent of the patient.)
• Reconciliation of all discharge medicine with pre-admission medicines, medications during hospitalization including over-the-counter medications.
• All known allergies.
• Immunization record, particularly influenza and pneumonia.
• Current and past smoking status.
• Alcohol or other drug use, legal or illegal.
• Vital signs, including pain level.
• Unique identifiers for any implantable devices, including their intended purpose, patient education information, name and contact information for the physician monitoring the device.
• Any special instructions or precautions for ongoing care.
• Patient’s goals and treatment preferences.
What to send to the Practitioner Responsible for Follow-up Care
• A copy of the discharge instructions and discharge summary within 48 hours of discharge.
• Pending test results within 48 hours of their availability.
• All of the necessary information listed above that must be sent to receiving facilities.
Source: 2016 Jackie Birmingham and the Centers for Medicare & Medicaid Services
What hospitals should consider in evaluating a patient’s discharge needs.
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