What the Discharge Planner Needs to Know in Order to Effect a Safe and Efficient Transition

  • Baseline information about the individual* such as their: current medical, psychological and mental health status, family and community support systems, payor source, financial status, decision making capacity (proxies, Do Not Resuscitate, Power of Attorney, Guardianship, Committeeship), religious preference, legal issues, Adult Protective Services involvement, environmental limitations, etc.
  • Does the individual have a community medical provider?
  • Would they like assistance in finding one?
  • What are the medical team's expectations regarding length of stay?
  • What are the individual's expectations/goals in terms of their long term plan and short term or immediate plan?
  • What are the expectations/goals of the informal supports assisting the individual?
  • What services did the patient have prior to admission/will same level of service be sufficient or is an increase in hours needed? Is provider willing to reinstate services? If not, why?
  • Are there any reimbursement restrictions or limitations of service providers involved with delivering services to the individual?
  • Who will be the medical provider responsible at home and what is the means of communication between providers from the hospital to the home setting? (In certain situations a medical provider other than a physician will be responsible. Please note that the rules vary regarding whether a non-physician such as a nurse practitioner who is able to sign orders for clinical purposes may do so for payment purposes).
  • Who or what entity has overall responsibility for checking the facts?
  • Are there any parameters or limitations affecting the patient's right to choose?
  • What constitutes "non-compliance" by the individual living at home, and how is that communicated to the home care provider (which may be a home care agency or a community services provider).
  • Can the non-compliance be addressed:
    1. Can it be fixed?
    2. Is there history of behavior that affects the individual's health and puts them at risk of imminent danger?
    3. Does patient have capacity?
    4. How serious is the risk?
    5. Are staff at risk/threatened?
    6. Is caregiver non-compliance/abandonment a factor?
    7. Is the back up plan realistic?
    8. Is there adequate care being provided?
    9. Is compliance linked to reimbursement?
  • Who or what entity should be notified should the home care entity determine that services cannot be delivered safely?
  • What is the range of available resources to the discharge planner to meet an individual's need?
  • Does the discharge planner know how to research the requirements for the various programs in their community?
  • What are the environmental limitations of the individual's residence and can the residence support the plan?

    For example:

    1. Is there 220 wiring to support any special equipment needs?
    2. Is there clean adequate water?
    3. Is the home clean and free from germs?
    4. Is the home debris free sufficient to prevent accident hazards in elderly and individuals with disabilities (for example a throw rug may not pose an accident risk for most people, but may for someone with an unsteady gait)?
    5. Does the home provide adequate access for an individual with disabilities or does the home require modifications?

* We have chosen to use the term "individual" to refer to the user of healthcare services. This includes the individual in the community, the patient in the hospital or the resident in a nursing home.