The primary goal of discharge planning is to ensure a patient’s smooth transition from the hospital to her home or another facility. Patients must be humanely and appropriately discharged when they are medically ready to leave the hospital. Senior patients who are unable to care for themselves cannot be sent home; medically incompetent adults cannot be brought to homeless shelters; and patients in need of vital medications or medical equipment should have them. The discharge planner (DP) must work with all parties involved in their patient’s care to make sure that she is cared for while also facilitating as expedient a discharge as possible to prevent a potential increase in hospital costs.
The Importance of Discharge Planning
Medicare mandates that all inpatient facilities that bill the program provide discharge planning services. The way discharge planning is performed and whose job it is varies in every state and community. Hospitals that employ qualified and experienced discharge planners may see the numerous benefits of their service, including:
- Shorter length of patient stay
- Fewer readmissions to the hospital
- Improved patient outcomes
- Higher reimbursement rates
- Strong advocates who ensure that patients’ rights and choices are respected
- Patients who are better connected to any needed resources or assistance
- Improved connections between the hospital and relevant community services
- The education of fellow staff members
- Assistance with complicated and potentially problematic situations
Who Are the Discharge Planners?
Hospital discharge planners are most often social workers or nurse case managers who arrange post-hospital services. As experts on matching patients with the community resources that best meet their needs, they handle the nuts and bolts of turning a discharge plan into a reality. Some hospitals employ a handful of discharge planners to cover multiple areas of the hospital. Others employ teams to look at multiple aspects of a patient’s potential needs; this team approach arms the discharge planner with multidisciplinary information to help her finalize an effective plan for her patient.
Discharge planning is primarily performed by medical social workers who are trained to prioritize patient choice, or the right to self-determination. The combination of a social worker’s interpersonal training, their extensive knowledge of insurance coverage for different services, and their experience networking with community providers helps ensure that patients are more likely to get the care that they will need when they leave the hospital. Throughout the process, the social worker focuses on the patient’s perspective along with his medical needs.
Nurses may also take on the role of the discharge planner. The patient’s medical needs and his physician’s orders are their principal areas of focus. While nurses do acknowledge a patient’s right to self-determination, they must follow a doctor’s orders without limitations set by the patient. Still, nurses are adept at interacting with potentially stubborn patients and have broader medical knowledge and experience. Unless the social worker is heavily experienced, they may not understand a medication list, for example, or the intricacies of good wound care as a nurse would.
Other healthcare professionals are sometimes enlisted to provide discharge planning, primarily to save costs. These might include practical nurses or those versed in social science or even business. Facilities with flagship discharge planning services will likely have master’s-level social workers, many of whom focused their studies on such related specializations as medical social work and geriatrics.
In facilities where discharge planning is comprehensive, case management and discharge planning are separate functions. They work in tandem, however — case managers and discharge planners are members of the same team, their roles dependent on one another. Case managers are usually registered nurses, often with advanced degrees, who are responsible for monitoring, coordinating, and facilitating a patient’s treatment in the hospital. By the time the patient is ready to leave the hospital, the DP has arranged all post-discharge services, including those recommended by the case manager.
Good discharge planning begins as soon as the patient is admitted, and it follows her no matter the day of the week or where she is located in the hospital. Because the discharge planning process varies so much, there is no single overarching procedure. Still, the following elements are found in most discharge planning procedures:
- An initial psychosocial assessment is obtained from the patient or family.
- A plan is developed that includes the patient or caregiver’s input throughout the process.
- Arrangements are begun early for any difficult or complex discharges.
- The patient is provided with information to help guide her choice of post-treatment options, such as a medical alert system.
- The physician’s orders for post-discharge services are synthesized with the patient’s consent.
- A plan is developed that is flexible enough to implement the physician’s orders while respecting the patient’s rights.
- The discharge planner contacts vendors chosen by the patient — often with guidance from her insurers, who might send representatives to the hospital.
- The vendor is supplied with the patient’s physician orders and medical records.
- At discharge, the DP verifies all services are in place and arranges transportation to a receiving facility or to the patient’s home.
- Unless the patient is going to another facility, the DP makes any necessary follow-up appointments and notifies the patient or her caregiver.
- The discharge planner calls the patient a couple of days after discharge to check on her. Any problems are identified, and the DP helps facilitate the process to resolve them.
Discharge Planners at Work
In large hospitals, discharge planners and case managers are stationed on nearly every unit. In addition to clerical support staff, PRN discharge planners — hospital discharge planning staff who work on an as-needed basis — are trained to cover any floor. Good documentation is thus critical to ensure a proper continuum of care.
The variety of settings, patient populations, employer expectations, and legal mandates make for a multitude of definitions of discharge planning. Here are several examples that illustrate some of those differences.
In the emergency room, the DP’s role is more social work than discharge planning, and few settings are a better match for a medical social worker. Some discharge planning is involved, such as the arrangement of home health services. Primarily, however, the ER social worker’s typical shift might involve helping people find shelter overnight, arranging transportation for families of air-evacuated patients, or simply visiting patients in their rooms and listening to their stories.
Orthopedic units care for patients before and after surgery. The majority of the DP’s patients in this department have had an elective knee or hip surgery or have had a fracture repaired. The discharge planner arranges home health or outpatient physical therapy and nursing services for some patients and arranges transfer to inpatient rehabilitation hospitals or skilled nursing facilities for others. Thus, the bulk of the orthopedic DP’s time is spent in discharge planning. There is less need for social work to help patients resolve obstacles to their care.
Adult medicine and medical/surgical units host patients with a variety of diseases and traumas. Some need minimal discharge planning services, while others may need the skills of a social worker. Public hospitals provide a significant amount of care to patients without the means to pay for treatment, and adult medicine units often host a high proportion of these patients. Much of the DP’s time here is spent finding funds for the services needed to discharge a patient from the hospital. Arranging substance abuse treatment and finding primary medical care for uninsured or underinsured patients are two of the daily challenges adult medicine DPs often face.
Discharge planners on the neurotrauma intensive care unit have very focused missions, as they work with patients undergoing major life changes. These DPs help patients and their families cope with brain trauma, spinal cord injuries, and stroke. They also work to find facilities that can provide the extensive care these patients will need when they leave the hospital — and must overcome the logistical challenges that may arise when one is found. The orthopedic and especially the neurotrauma floors are relatively quiet compared to the bustling emergency department and adult medicine units.
Patients on oncology units also face life-changing medical events. However, while neurotrauma patients may be coping with the effects of a sudden injury, oncology patients could be facing other medical challenges. Depending on the type and stage of cancer, discharge planning in oncology units may focus different approaches to treatment. DPs on this unit usually arrange home health and hospice care and sometimes serve as counselors. They, like the rest of the unit’s staff, work to ensure peace and comfort for patients and their families.
To be effective, discharge planners must be prepared for any challenge to their primary mission, whether that involves obtaining a language interpreter, finding a nursing home that will accept an exceptionally heavy patient, or convincing an insurance provider to make an exception for a high-cost medication that it normally does not cover. Hospitals that support discharge planning are aware that however much a discharge plan may cost, reducing length of stay is key. But most important, a good discharge plan ensures a patient’s medical needs and rights are provided for and honored.