Quick Guide to Discharge Planning and Continuity of Care

Patient care doesn’t stop after they leave the hospital. Patients need a holistic continuity of care plan enabling them to access vital follow-up healthcare services. Case managers who help manage discharge plans prioritize the patients’ well-being, consider resources and partner agencies, and use data to help inform their decisions.

Effective discharge planning decreases the odds that a patient is readmitted by ensuring they receive adequate care and supportive services during recovery.

Discharge plans are often prepared by case managers, social workers, nurses, or other personnel, and are authorized by the patient’s physician prior to patient discharge.

Discharge plans take into account a holistic view of the patient’s health and individual needs, and often involves setting up referrals with supportive organizations in the community – such as occupational therapists, primary care providers, home health care, skilled nursing facilities, hospice agencies, meal and medication delivery services, caregivers, or mental and behavioral health care providers. Discharge planners also consider the patient’s insurance coverage and parameters for the scope of certain services, such as personal care versus long-term care.

Developing a Discharge Plan

Proactive discharge planning begins when the patient is admitted to the hospital. The discharge planner evaluates the patient’s situation, and has a discussion with the patient or their representative about what their care will look like after they leave the hospital. They also take into account language preferences and coordinate translation services if necessary. Throughout the patient’s stay at the hospital, their discharge planner serves as a patient advocate.

Next, the discharge planner will develop a plan for homecoming or transfer to another care facility and determine whether additional caregiving support is necessary. Finally, the discharge planner coordinates care with other agencies and resources in the community, and arranges follow-up appointments or tests.

Discharge planning prepares and supports the patient after they leave the hospital and reduces the chances they’ll be readmitted.

• Personal Care: Eating, Dressing, Bathing
• Household Care: Cooking, Shopping, Cleaning
• Health Care: Follow-up Appointments, Physical or Occupational Therapy, Wound Care, Medical Equipment, Medication Management, Social Work, Home Health Visits
• Emotional Care: Mental Health Check-ins, Therapy, Companionship
• Crisis Planning: Wellness Recovery Action Planning and Wraparound Services, Illness Management and Recovery
• Patient Education: Who they can call if they have questions or an emergency? Nutritional Instructions, Allergies, Medications, Activity Restrictions, Follow-Up Appointment Reminders

Assessing Social Determinants of Health and Other Factors

Discharge planning should also take into account the patient’s social determinants of health – domains that can have tremendous impact on a person’s life and impact their ability to heal or access the care they need.

The factors of Social Determinants of Health include:

• Housing Stability: Homelessness, Housing Safety, Ability to Pay Mortgage/Rent
• Food Insecurity: Access to Adequate and Nutritious Foods
• Financial Strain: Funding Sources, Emergency Funds, Benefit Denial, Supportive Services, New Expenses Related to Care (I.e. Medication, Home Health)
• Transportation: Ability to Travel to and from Medical Appointments, Work
• Violence Exposure: Elder Abuse, Community Violence, Domestic Abuse
• Socio-Demographic Factors: Income Level, Immigration Status, Languages Spoken, Race and Ethnicity, Educational Attainment

An inability to address individual needs and stressors in these key areas may lead to hospital readmission, which is why it’s so important for discharge planners to have open conversations with patients and create personalized plans for each situation.