wk 7: discharge planning Flashcards
what are some general aspects to discharge planning?
-determine patients needs from one level of care to another
- be an advocate
-evaluate patients appropriateness for discharge
-discuss with patient and caregiver
-plan DC
-make referrals
-arrange follow up care
why is discharge planning so important ?
there are lots of changes : medications treatment plans, major surgery or Dx, wound or equipment
improves health outcomes
decreases readmission
poor discharge planning can lead to
medication mis-management
health decline
safety issues/ concerns
result in readmission to hospital
what is important to consider when discharge planning?
enough time to teach and return demonstration
assistance/help at home? how much do they need?
learner type
need caregiver to hear info?
what are some things that can make discharge planning difficult?
healthcare issues
lack of time
trying to get patient out quickly d/t needing room
family hesitancy to go home
social issues/transportation
appropriateness for discharge
are they ready?
do they have a plan to go home?
is the DC plan safe?
if the patient or caregiver feels it is too early, you can appeal it
determining post-discharge site of care
home
home with home health
skilled nursing facility (SNF)
inpatient versus outpatient rehab
long-term acute care facility
critical aspects involved with discharge planning?
medication reconciliation
diagnosis
procedure
surgery
diet
activity
case management/ social services
follow-up appointments
medication reconciliation
review home meds
review hospital medications
anticipate new meds
how will they obtain medications? (insurance, co-pay)
diagnosis explanation for discharge
brief description of Dx
how did we treat it in the hospital
special requirements/recs
when to call HCP
when to seek out immediate attention/ ER
procedure or surgery discharge planning
give brief description of procedure or surgery
home care
follow up care
when to seek medical attention
diet discharge planning
what diet? specifics
what foods are good/bad
consult dietician
plan grocery list
talk through favorite foods (do they need to modify?)
DC planning: activity
what can/ cant they do
new mobility issues ?
house layout
discharge planning for: case management/ social services?
need any durable medical equipment (DME)
home health (skilled nursing, wound care aide, PT/OT/SLP)
financial assistance with medications?
home life- running water, electricity, etc..
discharge planning: follow up appointments
HCP in one week (they make appt)
follow up speciality (live far from main office, satellite locations, tele-health)
who to contact with questions
do they have transportation
