Transitions of Care: Discharge Planning

Alexa Serino

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

Discharge planning should begin upon admission 

  • Why is the patient being admitted, what needs to be resolved before they leave? 
  • Social history is important – 
    • Where do they live? – important for follow up, SNF/home health referrals 
    • Who lives at home with them? Can that person be a caretaker? – have a higher threshold to return home without help, consider home health nursing or assistance with medications 
  • Place disposition consults on admission: PT/OT, SLP, social work

During Hospitalization 

  • Think about a daily discharge checklist – LMNOP 
    • Lines: O2, foley, drains – what is attached to the patient’s body they did not enter the hospital with? Will they be discharged with this? 
    • Meds: IV to PO, restart anything we’re holding, using prns? 
    • Nursing orders – If this were copied to a SNF or at home could they do everything we’re doing in the hospital? Wound care, glucose checks etc. 
    • Outpatients follow up: Who was consulted? When to follow up? May need to page to arrange “closer to discharge” 
    • Procedures: Are there surgery/procedure specific recommendations for flushing/activity restrictions/suture removal? 
  • Talk to patients about discharge plan updates. If they have concerns about the plan, we need time to address it. 
    • Do they transport home or to follow up appt? 
    • Do they have a PCP? Insurance? 
      • Talk to CM about applying for OORA if insurance not covered with Vanderbilt and they need care with Vanderbilt subspecialist 
    • Can they afford the new medication we’re prescribing 
      • CM and pharmacy can apply for grants ahead of time and run prior authorizations 
  • Huddle is the time to meet with case management, social work, PT to discuss plans for discharge 
    • Reach out to case management early in the day if you have questions, huddle should be a time to close the loop.
    • Huddle example : “This is a 70 year old male admitted for MRSA bacteremia. He will be medically ready in 2 days once ID has final recs. PT OT recommended home health. He will need IV antibiotics at discharge.”

Discharge summary 

  • The most important section is “Action items at follow up” What needs to be done or followed up on once they leave the hospital? 
  • Include incidental findings that need to be followed up 

  • At Vandy to send a copy to provider, click the “routing icon” at the top of the screen 

  • At VA, make sure to tag PCP in discharge summary 
  • You must REFRESH the discharge summary before signing if you make changes to orders, otherwise the medication list will not update.

Patient Instructions 

  • Use the free text to emphasize important details 
    • You were admitted for *** found to have *** and treated with *** 
    • Medication changes 
    • Follow up appointments 
    • You can use VUMC AIchat tool to assist with specific steps or translation of instructions

Additional Resources

  • For patients requesting financial, legal, or housing assistance, make case management or social work can aware during huddle or via consult
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