The benefits of a successful discharge plan
It is critical to have a solid system for discharge planning that begins even before the resident is admitted to the facility. Individualized, resident-centered discharge planning will provide a solid system for quality transition and a crucial component of care at the preadmission assessment process.
In February 2013, the Office of Inspector General put out a report titled, “Skilled Nursing Facilities Often Fail to Meet Care Planning and Discharge Planning Requirements.” The OIG, also in March of 2014, addressed 25 “Priority Recommendations,” in which No. 9 reiterates: “Nursing homes — Improve care planning and discharge planning for beneficiaries in nursing home settings.”
CMS also gives specific requirements on discharge planning in its State Operations Manual in section F284. Some of the probes pertain to determining if the discharge summary has information regarding the continuing care of the resident; evidence that the discharge assessment needs for development of a discharge plan; and the preparation and education provided to the resident and/or family, post discharge care and services, etc.
How can we operationalize this process for success? First, determine your current system and compliance. Review of the policy and procedure will tell you if your directions to staff are consistent with the requirements.
Next, review your system for compliance:
- Preadmission assessment: Are you addressing discharge wishes and planning needs in order to be prepared prior to admission?
- Admission: Are you completing a comprehensive assessment with the interdisciplinary team, including the physician and therapy, to identify individualized discharge planning needs?
- RAI process: Are all components in place — including the CAA for Return to Community Referral? Are you completing the section identified for resident and family input to ensure person-centered discharge planning?
- Do you have a care plan that clearly outlines realistic and measurable goals and approaches identified to meet residents' needs?
- Are all staff members aware of the goals and approaches, and is there evidence of documentation for consistent implementation?
- Do you have a clear education system for the resident/family that documents ongoing (from the time of admission, when appropriate) teaching, return demonstration or other evidence of successful training for post-discharge care (including medication management, equipment or device training, medical management, scheduled calls to the doctor, etc.)?
- Is there evidence of coordination of services that the resident will need once discharged from the facility?
- Do you provide (and keep a copy) of materials for the resident and/or family with clear care instructions and training upon discharge?
- Is there evidence in the record of follow-up once resident is discharged?
Keeping good documentation of the process as well as ensuring that the entire Interdisciplinary team is involved will be instrumental for the success of a good discharge plan.
Susan LaGrange, RN, BSN, NHA, is the national education coordinator at Pathway Health.