Hospital leaders are placing added emphasis on planning for what will happen after patients leave their four walls. Discharge planning has become all the more important given the new reality in which providers not only are taking on more risk and are responsible for episodes of care, but also are being dinged for avoidable readmissions.

Each hospital’s circumstance is unique when it comes to discharge strategy, and no one solution will work for every institution. With that in mind, the American Hospital Association recently released a new set of tools to help smooth patient transitions to home, rehabilitation or any other setting.

Private-Sector Hospital Discharge Tools includes case examples from five hospitals around the country, and it’s tailored to all types of institutions [you can read the full report at].

Besides hospitals and providers, the report targets policymakers who are looking to improve overall episodes of care. Rochelle Archuleta, senior associate director of policy for the AHA, hopes that politicians see the tools offered in the report as a sound alternative to onerous regulations. “We think that this is an opportunity for policymakers to look toward innovators in the field to learn about some effective ways of improving the discharge process, without implementing a tremendous amount of burden,” she says.

Here are five key patient discharge lessons from the case studies:

1 | Where a patient is placed after discharge, above all else, should be based on clinical needs. Such clinical decision-making is key to designing future payment models.

2 | The design of discharge planning tools should include input from treating clinicians. Once a patient heads home, planning should include other nonclinical variables, such as geographic proximity and the availability of family support.

3 | The tools also must be administratively feasible for hospitals and free of redundancies without adding to the current reporting burden.

4 | Discharge planning tools should focus on helping doctors and nurses to optimize a patient’s health and to facilitate restored function when he or she returns home.

5 | Hospitals should design discharge planning tools in ways that facilitate the capture of standardized data on patients.