--- name: conducting-discharge-planning-nursing language: en description: Coordinates nursing discharge planning with medication teaching, follow-up scheduling, and resource coordination. Use when planning discharge, coordinating post-discharge care, or documenting discharge teaching. tags: - process - nursing metadata: author: casemark practice_areas: - Nursing - Advanced Practice - Nurse Practitioner document_types: - Process Documentation skill_modes: - Process Management --- # 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. --- ## 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 --- ## 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 --- ## 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) --- ## 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. --- ## 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 --- ## 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 --- ## 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 --- ## 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 --- ## 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 --- ## 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