conducting-discharge-planning-nursing

# Conducting Discharge Planning Nursing

## Why This Skill Exists

Discharge planning is a CMS Condition of Participation (§482.43) requiring hospitals to have a discharge planning process that applies to all patients. Effective discharge planning reduces 30-day readmissions — a CMS quality metric under the Hospital Readmissions Reduction Program (HRRP) that imposes payment penalties for excess readmissions for heart failure, acute MI, pneumonia, COPD, THA/TKA, and CABG. The Joint Commission requires a coordinated, patient-centered discharge process. ANA Standard 5 (Implementation) includes coordination of care and Standard 5B includes health teaching as core components. HCAHPS discharge information domains directly affect hospital reimbursement under Value-Based Purchasing. Poor discharge planning contributes to medication errors at transitions (an estimated 60% of medication errors occur at care transitions), patient confusion, missed follow-up, and preventable readmissions.

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## Checkpoint A — Intake Verification

### Required Patient Information
- [ ] Current medical diagnoses and problem list
- [ ] Current functional status: mobility, ADL independence, cognitive function
- [ ] Discharge disposition: home, home with services, SNF, LTACH, inpatient rehab, hospice
- [ ] Social determinants of health: housing stability, transportation access, food security, caregiver availability, insurance status
- [ ] Patient/family goals and preferences for post-discharge care
- [ ] Advance directives and code status (relevant for skilled nursing or hospice transitions)
- [ ] Language, literacy, and cultural considerations

### Required Clinical Information
- [ ] Discharge medication list (reconciled against admission medications)
- [ ] Pending diagnostic results that may affect discharge plan
- [ ] Outstanding consults or procedures
- [ ] Activity restrictions and weight-bearing status
- [ ] Dietary restrictions or requirements
- [ ] Wound care or ongoing treatment needs
- [ ] DME (durable medical equipment) requirements
- [ ] Follow-up appointment requirements (PCP, specialist, surgeon)

### Screening for Post-Discharge Risk
- [ ] LACE Index score or institutional readmission risk tool completed (Length of stay, Acuity of admission, Comorbidities, Emergency department visits in prior 6 months)
- [ ] High-risk medication regimen identified (anticoagulants, insulin, opioids, immunosuppressants)
- [ ] History of prior 30-day readmission
- [ ] Lives alone or has inadequate social support
- [ ] Three or more active comorbidities

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## Step 1 — Initiate Discharge Planning on Admission

Discharge planning begins at admission per CMS CoP §482.43:

1. **Screen** all patients within 24 hours of admission for discharge planning needs using institutional screening tool
2. **Identify** patients requiring formal discharge planning evaluation:
   - Patients with complex medical needs
   - Patients likely needing post-acute services (home health, SNF, rehab)
   - Patients with inadequate social support or housing instability
   - Patients with readmission risk factors
3. **Initiate** interdisciplinary discharge planning team involvement: case management, social work, physical therapy, occupational therapy, dietitian, pharmacy as appropriate
4. **Set** an estimated discharge date (EDD) and communicate to patient/family and care team
5. **Document** the initial discharge planning assessment in the medical record

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## Step 2 — Conduct Medication Reconciliation for Discharge

1. **Compare** the current inpatient medication list against the pre-admission medication list
2. **Identify** medications that were: continued, modified (dose/frequency change), added (new), or discontinued during the hospitalization
3. **Resolve** discrepancies: For each changed medication, document the clinical rationale
4. **Verify** the patient/caregiver can obtain all discharge medications:
   - Insurance formulary coverage
   - Pharmacy access
   - Cost barriers (coordinate with social work or pharmacy for patient assistance programs)
5. **Generate** the discharge medication list in plain language with:
   - Medication name (generic and brand)
   - Purpose
   - Dose, frequency, route
   - Special instructions (take with food, avoid grapefruit, etc.)
   - Common side effects and when to contact provider
6. **Highlight** high-risk medications requiring additional teaching (anticoagulants, insulin, opioids)

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## Step 3 — Provide Discharge Education Using Teach-Back

Mandatory education topics per CMS and Joint Commission requirements:

1. **Diagnosis understanding**: What was wrong, what was done, and current status in plain language
2. **Medication review**: Review each discharge medication using the reconciled list; use teach-back
3. **Activity restrictions**: Specific limitations (no lifting > 10 lbs, no driving for 2 weeks, etc.)
4. **Diet**: Specific dietary requirements or restrictions with written instructions
5. **Wound care / ongoing treatments**: Demonstrate and have patient/caregiver return-demonstrate
6. **Follow-up appointments**: Confirm dates, times, locations, provider names; address transportation
7. **Warning signs**: Specific symptoms requiring emergency care vs. provider contact
   - Use condition-specific red flags (e.g., CHF: weight gain > 2 lbs/day, worsening SOB; surgical: fever > 101.5°F, wound drainage change)
8. **Equipment use**: Demonstrate any DME (oxygen, glucometer, wound vac, etc.)

Document teach-back results for each topic. Reference managing-patient-education skill for detailed teaching methodology.

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## Step 4 — Coordinate Post-Discharge Services

1. **Home health referral**: Submit orders for skilled nursing, physical therapy, occupational therapy, speech therapy, home health aide as indicated; ensure referral includes specific visit frequency and duration
2. **SNF/LTACH/Rehab placement**: Coordinate with case management; ensure medical records transfer; confirm bed availability; arrange transportation
3. **DME coordination**: Order equipment, confirm delivery date/time, arrange for patient/caregiver training
4. **Outpatient services**: Schedule follow-up appointments before discharge; PCP follow-up within 7 days (within 48 hours for high-risk patients)
5. **Community resources**: Connect patient/family with disease-specific support groups, nutrition programs, transportation services, pharmacy assistance programs
6. **Caregiver support**: Assess caregiver burden; provide caregiver education and respite care resources

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## Step 5 — Execute Day-of-Discharge Protocol

1. **Confirm** all discharge orders are complete and signed
2. **Verify** discharge medication prescriptions are transmitted to pharmacy or provided to patient
3. **Perform** final medication reconciliation at discharge — compare what patient received inpatient against discharge orders
4. **Complete** all discharge education with documented teach-back
5. **Provide** written discharge instructions: medication list, follow-up appointments, activity restrictions, dietary instructions, warning signs, emergency contact numbers
6. **Ensure** patient has follow-up appointment confirmed (not just "call to schedule")
7. **Arrange** transportation
8. **Remove** IV access, urinary catheter, and other devices not needed post-discharge
9. **Perform** final assessment: vital signs, pain assessment, ambulation status
10. **Escort** patient to vehicle per institutional policy

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## Step 6 — Document the Discharge

1. **Discharge summary note**: date/time, condition at discharge, mode of transport, accompanied by whom
2. **Discharge medication list**: complete reconciled list with patient/pharmacy copies
3. **Discharge instructions**: all topics covered with teach-back results documented
4. **Follow-up plan**: appointment dates, provider names, pending results with follow-up plan
5. **Referrals placed**: home health, DME, outpatient services with confirmation
6. **Patient education**: topics covered, materials provided, learner identified, teach-back results
7. **Advance directive status**: confirmed and communicated to receiving facility if applicable

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## Checkpoint B — Discharge Readiness Review

### Patient Readiness
- [ ] Patient/caregiver can verbalize diagnosis, medication regimen, warning signs (teach-back confirmed)
- [ ] Patient/caregiver can demonstrate any required skills (wound care, injection, equipment use)
- [ ] Patient has transportation arranged
- [ ] Patient has medications or prescriptions in hand
- [ ] Patient has written discharge instructions in preferred language

### System Readiness
- [ ] All discharge orders complete and signed
- [ ] Medication reconciliation completed with discrepancies resolved
- [ ] Follow-up appointments confirmed (not just recommended)
- [ ] Home health/SNF referral submitted and confirmed
- [ ] DME ordered and delivery confirmed
- [ ] Discharge summary dictated/completed for PCP communication
- [ ] Transition record sent to receiving provider/facility per CMS requirements

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## Quality Audit

- [ ] Discharge planning initiated within 24 hours of admission per CMS CoP §482.43
- [ ] Readmission risk screening completed with appropriate interventions for high-risk patients
- [ ] Medication reconciliation performed at discharge with discrepancies resolved and documented
- [ ] Teach-back documented for all required discharge education topics
- [ ] Follow-up appointments scheduled before discharge (PCP within 7 days for general; 48 hours for high-risk)
- [ ] Written discharge instructions provided in patient's preferred language at appropriate literacy level
- [ ] Condition-specific warning signs included in written instructions
- [ ] HCAHPS discharge information domains addressed: understanding of care at home, understanding of medication purpose
- [ ] 30-day readmission rates tracked per CMS HRRP conditions
- [ ] Discharge process compliant with CMS CoP §482.43, Joint Commission standards, and ANA Standards 5 and 5B

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## Guidelines

- **CMS CoP §482.43**: Hospitals must have a discharge planning process; evaluate patients for discharge needs; develop discharge plans; arrange for post-hospital services
- **CMS HRRP**: Hospital Readmissions Reduction Program penalizes hospitals with excess 30-day readmissions for specified conditions
- **Joint Commission**: Transition of care standards require coordinated discharge with patient engagement, medication management, and follow-up
- **ANA Standards**: Standard 5 (Implementation) includes coordination of care; Standard 5B (Health Teaching) requires education for self-management
- **HCAHPS**: Discharge information domain questions directly affect hospital reimbursement
- **Medication reconciliation**: Joint Commission NPSG.03.06.01 requires medication reconciliation at every transition of care
- **Health literacy**: Discharge instructions must be at or below 6th-grade reading level; use teach-back to verify comprehension
- **Scope of practice**: RN coordinates discharge planning, performs medication reconciliation, delivers and evaluates discharge education; case management arranges post-acute services; social work addresses psychosocial barriers; pharmacy reviews medication reconciliation for high-risk regimens
- **Post-discharge follow-up**: Evidence supports follow-up phone calls within 48–72 hours of discharge to reduce readmissions; include medication review, symptom assessment, and appointment confirmation