Discharge Planning

Christine Hamilton

Discharge from hospital represents a period of vulnerability for patients. Medical errors (especially medication errors) following discharge are exceedingly common.

On Admission

  • Verify PCP, primary specialty providers, social support, current living situation, and functional status on arrival.
  • Careful med rec, track any new meds, held/stopped meds, and med dose changes from the beginning
    • Review all meds with patient/family
      • Make sure to discuss any OTC medications and herbals as they can have significant interactions
    • Check recent notes/transfer documents for any recent changes.
    • Use dispense history in Epic to assess adherence or if information is limited.
  • Consult PT/OT early for anyone who you anticipate may need home health services or need to be discharged to any location besides home

During hospitalization

  • During team rounds: consider barriers to discharge daily
  • In huddle, discuss anticipated discharge timing, destination, and any other needs
  • With patients and families: discuss discharge timing to set expectations
  • Track any incidental findings or things for PCP to follow-up (e.g., incidental nodules on scans: use .vnincidental) within the “hospital course”

On discharge day

  • Communicate with patient’s outpatient team (e.g. PCP)
    • Typically achieved through the discharge summary
      • Include a list of specific, actionable follow-up tasks and assign a responsible party. Place in easy-to-view spot at the top of the summary
        • E.g., Instead of writing “follow-up BMP after initiation of furosemide,” write “PCP to check BMP in 2 weeks after initiation of furosemide”
        • Include any pending studies and appointments from hospital admission
      • All relevant parties should receive a copy of the discharge summary (see appendices section for mechanics of discharge process)
        • It is useful to send patient with a printed copy of the discharge summary if they will follow-up outside VUMC
        • Route a copy of your DC summary to a specific party using the routing function under the Epic discharge tab
    • For high-risk discharges (poor health literacy, hx of being lost to follow-up, follow up outside VUMC), consider calling PCP’s office to set follow-up
  • Complete an accurate and thorough medication reconciliation
    • An accurate discharge medication list depends on having a complete admission medication reconciliation (utilize Pharmacy Consult!)
  • Steps
    • Identify and medication changes, including to route, dose, or frequency.
    • Check the MAR to be sure patient has been accepting offered medications while in hospital.
    • Assess medications and dosages are appropriate.
      • Review with the team and pharmacist if possible the day before discharge!
      • Use this as an opportunity to deprescribe to reduce pill burden and potential harms
    • Clearly document any medication changes in patient discharge instructions and the discharge summary.
      • Can include follow up tasks if pertinent (ex: PCP to follow-up BP in 2 weeks. Losartan held on d/c due to AKI but anticipate need to reinitiate once CR normalizes)
    • Review all important medication changes with the patient and/or caregiver.
  • Ensure that appropriate resources and follow-up appointments have been requested* (PT/OT, skilled or non-skilled nursing HH, PCP follow-up, etc.)
  • Effectively communicate discharge plan to patient
    • Discuss medication changes, tasks for patient to complete, follow-up appointments
      • Key points should also be written in the patient instructions box
      • Useful to include educational sheets in the AVS (searchable in discharge navigator)
      • Utilize teach-back method to ensure your instructions were effectively communicated
  • At VUMC we are fortunate to have the Discharge Care Center
    • Multidisciplinary team including nurses, social workers, care coordinators, and pharmacists
    • Phone number is included on discharge paperwork, and patients can contact them 24/7. The DCC also reaches out to patients through an automated system
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