What strategies can physicians use to ensure they are aware of patient's discharge plans?

It is extremely important that patients are well-prepared for discharge, receiving all essential information with dedicated time. Procedures are explained, and informational materials are provided in both analog and digital formats. Collaborative documentation, involving multiple professionals, can also assist in understanding the next steps to avoid knowledge gaps. 📋🤝

I think for me who has been a RN CCM for many years in several different settings, the answer is not hard : communicate with us. Many discharge patients without even notifying us, don’t read our documentation, listen to our concerns along the patients journey across the continuum of care regarding barriers or dismiss how important our rolls altogether. Some not all.

What strategies can physicians use to ensure they are aware of patient's discharge plans? Physicians can use an interdisciplinary approach utilizing Social Workers, Nurses, PTs, OTs, etc. to ensure they are aware of discharge plans. The collaborative approach could ensure there is no service duplication and no patient's "fall through the cracks."

An example of this is when the multi disciplinary team works together in service delivery. Case managers are the glue to the physicians and patient relationships. Case managers are also able to monitor the patient even when at home through the help of community caregivers.

I will take a different tack. I have several “Please Don’t” requests: Please don’t promise how long a patient will be in a rehab facility. Please don’t promise private rooms. Please don’t send requests when the patients are at their base line. Please don’t tell patients they will be independent when they return home These things put the facilities in impossible positions which directly affects their satisfaction scores. Home health is an appropriate option for many patients, and statistics show that they get better faster (and with fewer instances of hospital acquired infections) in their own home environments with proper education and care planning.

A physician should stay updated about a patient's discharge by staying in touch with the whole interdisciplinary team, asking relevant questions, and consistently joining care plan meetings. This proactive approach ensures awareness of the discharge plans. Additionally, engaging with the patient and their family helps understand their concerns and requirements for a safe transition home, preventing future hospital visits. It's about maintaining effective teamwork and communication to ensure a smooth and secure transition for the patient post-hospitalization.

I agree with this statement, but in my experience this doesn’t always happen because physicians sometimes are disrespectful and angry. This makes it hard to have effective communication. Then the case manager has to act as a negotiator, which is an art in itself, just to get an agreement on what is best for the patient and the organization. Respect goes a long way. Case managers are gold! Why should the case manager have to be subjected to that behavior?

The best discharges include all members working as a team with no one's role more important. Keeping patient and their support system the center of discussion means that the chances of success improves with discharge. Ignoring lack of support just to discharge usually means they'll return.

Read the chart. All your questions will be answered! At least it was in my case. I always had the discharge ready for the doctor in a manner that was a quick read for their busy day. Keep communication to the point!

Even if you do your discharge summary digitally and get everything situated.... get it in writing, you just never know what can go awry.

This where a family meeting would be beneficial and if possible the home care case manager involved. Making sure everyone understands their role in the patients care and that one individual isn't tasked with too much. Seeing a return demonstration in the hospital and again at home. Making sure all necessary resources are available in the home. Using motivational interviewing making sure the patient, family and caregiver are all on the same page.

Discharge is a team process, and there is no team if family members are not involved. Good communication and planning can ensure that clients get to stay home and not need to be rehospitalised because of a care issue the family was unaware of or not trained for.

I've seen this happen too many times; individuals are discharged and the family caring for the Individual knows absolutely nothing on what to do. In my personal opinion, I would encourage case management to check in with the tasked family member at least once a week via phone and pop in physically every other week.

The more patient and their support are involved the more it reflects true needs. They tend to "own it " more when they are invested and feel listened to.

This is great. I’ve always admired families who were willing to sit and have a family meeting to discuss the patients progress and after care treatment. In my experience, we would always have a family meeting right before discharge, with the patients consent. Everything wasn’t always glitter and gold, but even then, everyone got hear one anothers concerns and address them as a whole. This allowed patients and their families to move forward with goals and roles in care post discharge. Family meetings are also the perfect setting to review safety plans. Explaining what warning signs to look for in the patients mental health and identifying things that will help.

Discharge planning is crucial in patient care as it ensures a smooth transition from the hospital to the patient's home or another healthcare facility. This process helps in preventing unnecessary readmissions, promotes better patient outcomes, and enhances overall patient satisfaction.

Die effektive Zusammenarbeit zwischen Ärzten, Apothekern, Pflegepersonal, Angehörigen und dem Patienten selbst ist von grundlegender Bedeutung, um auf modernstem Niveau eine optimale und wirksame Heilung zu gewährleisten, bei der jede beteiligte Partei einen essenziellen Beitrag leistet. Je besser und klarer hier kommuniziert wird, desto besser auch das Ergebnis am Ende der Behandlung

Closed mouths don't get fed, ever. There's absolutely no shame in deligating and/or asking for help. Also as a case manager, you physically and mentally can not be everywhere at once.

As a former nurse the discharge planning for a patient from hospital to home or alternative community setting is critical, especially for those with ongoing needs. Typically, a number of entities may be involved in ongoing care and support. The planning done at the hospital gets the process started but continues well post-discharge. Communication, including timely detail sharing is essential. A PCP can become the community organizer but all efforts need to be coordinated with the patient’s payer in order to facilitate coordinated and appropriate resources are available to support the patient outside of the hospital.

The old saying theee is no I in team is very true. Collaboration means team members are talking and sharing. Often a case manager is in unique postion to link to/ provide resources when they have whole picture.

I totally agree with this. I am 8 years into the social work world and so many things have changed from the very beginning of my career. With so many changes over the decades, we all must motivate ourselves to stay up the latest trends and continue to learn post graduate school. In addition, receiving continuous feedback and setting self goals for improvement, also helps to move forward.

Stimme ich voll zu. Die kontinuierliche Weiterentwicklung sowohl für medizinisches Führungspersonal als auch für medizinische Pflegekräfte ist unerlässlich, insbesondere angesichts der modernen Hilfsmittel wie KI in der Medizin. Durch ständige Fortbildung bleiben sie auf dem neuesten Stand und sind besser gerüstet, die Potenziale dieser Technologien effektiv zur Verbesserung der Patientenversorgung einzusetzen.

This summary hits all the high points for this topic! Ongoing education and being informed of the most recent best practices as well as CMS changes is important to discharge planning. This is not only applicable to the physicians but to the care coordination staff as well. Understanding the requirements for skilled nursing versus acute rehab, for example.

We are at a point where the insurance companies run the healthcare system. They basically control EVERYTHING patients receive. As CM we know this. Sometimes, patients have a preconceived notion that they have “good insurance” that covers everything. Unfortunately, we know that no insurance covers everything that patients may WANT. So, physicians should focus on medical treatment of patients and stop promising them what they are not sure patients can get, because it is the case manager who tries to explain the situation to the patient who now becomes the enemy. The physicians should understand that not ALL ORDERs are considered “Medically Necessary” with insurance. The fact that it is ordered may not be deemed necessary by the payor.

I agree with all the commentaries. An interdisciplinary approach must be made for a comprehensive discharge plan. I might add that the discussion of what are the patient’s goals be initiated upon an admission to the hospital. There are times that the discharge plan may be more appropriately routed to palliative or hospice care. This is a difficult conversation that needs to be increased by all providers.

Self care. I tell this to my unit on a bi-weekly basis. Case management can wear you out and eat you up if you don't take care of yourself.... as givers we can pour from all types of wells and never fully run dry; however if you don't pour into you... you lose you.

I truly don’t understand why we have let patient/family education go by the wayside. Once upon a time there were basic roundtable discussions between families,the patient if able as well as the providers and case managers to discuss obvious and possibly non-discussed needs from day 1. I guess I am just an old school nurse who was taught that discharge education started at admission to ensure everyone was on the same page and needs were going to be met appropriately. Maybe there’s something to be said about old fashioned education.

In my experience working in the system that I was in the role of CM changed from helping to being a bouncer. I love that my time doing CM/SW has given me knowledge, experience and a lot of take homes. But, the pros and cons did not balance for MYSELF based on the system I was in. Loved the initial work but not the new role.