Hospital discharge planning has garnered increased attention in the new era of value-based and accountable care as organizations seek to avoid readmissions while also strengthening connections with downstream post-acute care partners.
But it’s not just the desire to avoid readmission penalties that’s driving this new focus on discharge planning. Joint Commission standards are calling for it as well.
“Starting the plan for discharge/transfer upon admission allows staff to anticipate what type of ongoing care needs a patient may require,” says Phavinee Thongkhong-Park, R.N., associate director of the Joint Commission’s Department of Standards and Survey Methods. “Early planning gives the hospital more time to work with the patient and/or the family to identify resources available and find services to better meet the individualized needs of the patient.”
The Joint Commission requirements include having a process in place, noting the reasons and conditions for the patient’s discharge or transfer and the method for shifting responsibility from one clinician, hospital, program or service to another.
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Standards go further for hospitals seeking Joint Commission deemed status, a level of accreditation that means they meet or exceed Medicare or Medicaid requirements. This includes reassessing a patient’s original discharge plan after a certain period to ensure that it still meets the patient’s needs.
Patient education is required for this level of accreditation. Patients must be told of the kinds of services they will need, patients and family must be told how to obtain the needed continuing care and treatments, and organizations must provide the patient with the information needed to make a follow-up appointment.
There are also requirements for communicating with the receiving provider.
“The hospital must have a process to receive or share information when the patient is transferred or discharged, either to another organization or home,” Thongkhong-Park says. “The hospital’s process for hand-off communication allows for a discussion between individuals exchanging patient information.”
Requirements include informing receiving providers about the reason for the patient’s discharge or transfer, the patient’s physical and psychosocial status, the patient’s progress toward goals, and medication orders at the time of discharge or transfer.
Joint Commission surveyors use patient-tracer methodology to evaluate an organization’s discharge-planning process. This includes observing the process to confirm that the plans are individualized, and talking to patients, providers and others involved in discharge planning and, when appropriate, family members, Thongkhong-Park says.
The patient interview includes confirmation that a follow-up visit has been arranged, the patient has a walker or crutches if needed, and he or she can perform self-care at home. That includes being able to recognize the symptoms of an infection and the ability to perform an incision to prevent infection.
The Joint Commission has publicly available resources on discharge and transition of care planning at its Transitions of Care portal.
Andis Robeznieks is based in Chicago.