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IDEAL Discharge Planning

Discharge planning is the process of identifying and preparing patients for their anticipated health care needs after they leave the hospital. Ensuring a safe transition from hospital to home requires a systematic approach that includes participation from clinicians, hospital staff, patients and their families. Even though no consensus exists on the best method to prevent adverse events after leaving a hospital, AHRQ developed an implementation handbook, “Care Transitions from Hospital to Home: IDEAL Discharge Planning”1 to help hospitals develop effective strategies to improve patient safety.

Discharge from hospital to home requires the successful transfer of information from clinicians to the patient and family to reduce adverse events and prevent readmissions. In one study, 19% of patients experience an adverse event within 3 weeks of discharge.2 Of these adverse events, more than 60% could have been prevented or ameliorated. Common complications post-discharge include adverse drug events (66%) followed by and procedure-related injuries (17%).2

In another study, nearly 20% of Medicare patients were re-hospitalized within 30 days after discharge.3 About half of the readmitted patients did not see an outpatient doctor during the 30 days following the discharge.3 Of those patients discharged with medical conditions, 68.9%were re-hospitalized or died within one year after discharge, and, of those discharged after surgical procedures, the rate was 53%.4 The total cost of these repeat hospital stays is estimated to be between $25-$45 billion.5

The IDEAL Discharge Planning strategy helps make this transition safer and more effective. Key elements of the strategy include:

Include the patient and family as partners in the discharge planning process. Identify which family members or friends will provide care at home and include them in conversations.

Discuss five key areas to minimize problems at home:

  1. Describe what life at home will be like. Include home environment, support needed, dietary requirements, and which activities to do or avoid.
  2. Review medications. Use a reconciled medication list to discuss the purpose of each medicine, proper use, and potential side effects.
  3. Highlight warning signs and problems. Write down the name and contact information of someone to call if there is a problem.
  4. Explain test results. If test results are not available at discharge, let the patient and family know when they would be available.
  5. Make follow-up appointments. Make sure that the patient and family know what follow-up is needed.

Educate the patient and the family in easy-to-understand language the patient’s condition and the upcoming discharge process throughout the hospital stay.

Assess how well doctors and nurses explain the diagnosis, condition, and next steps to the patient and make improvements as needed.

Listen to and honor the patient and family’s goals, preferences, observations and concerns.

Implementing comprehensive discharge planning with the patient and family contributes to improved patient outcomes, including reductions in unplanned readmissions and increases in patient and caregiver satisfaction.6,7 The IDEAL Discharge Strategy can be used on its own or in conjunction with other initiatives, including RED (Re-engineering Discharge),8 the Care Transitions program,9 and BOOST (Better Outcomes for Older Adults Through Safe Transitions).10