Discharge Planning Workgroup

August 31, 2005

Ms. Linda Lambert, Executive Director
New York American College of Physicians
100 State Street
Suite 700
Albany, NY 12207

Dear Ms. Lambert:

The New York State Department of Health (DOH) and State Office for the Aging (SOFA), in response to increased safety concerns for patients, sought to examine the challenges and complexities experienced by discharge planners and members of the interdisciplinary care team in securing a safe and appropriate discharge for patients, regardless of the setting. To this end, DOH and SOFA brought together providers from the continuum of care, consumer advocacy groups and various offices within DOH, as a workgroup, to examine the challenges of patient transfers between the levels of health care. This letter is to share with you and your members the background information and some of the results of that work. In this context, discharge planning refers to individuals who are transitioning between settings of care (e.g., patients discharged between hospitals and skilled nursing facilities (SNFs), assisted living residences and home, in any combination of settings).

Over the past several months the workgroup has examined such issues as the timely sharing of accurate patient information between settings, the need for more discharge planner education about the breadth and depth of post-acute care services, and barriers that complicate the discharge/transition process for health care professionals and consumers (including the patient and their family). A major charge of the workgroup was to identify for discharge planners, in all settings, guidelines regarding the multidisciplinary information that must be compiled and understood, in order for the care team to affect a safe and appropriate discharge for the patient.

Recognizing that physicians are critical members of the care team, the workgroup has entered the next phase of the project and is seeking your comments and collaboration. The uniqueness of the physician–patient relationship is the source of a wealth of information that affects discharge planning. Such information obviously includes the patient's medical conditions, prognosis, and his/her functional and psychosocial status and needs. Equally important to the discharge planning process are the physician's valuable insights into the more private aspects of a patient's life such as social supports, living environment, and socio-economic history that can have a significant impact on the care needs of the patient transitioning through the continuum of care.

A product of the workgroup's efforts was a "Discharge Planners Checklist" that is enclosed with this letter. The checklist was developed as a guide for discharge planners in all settings to assist them in identifying and collecting the critical patient-specific information that is needed to plan and help the patient and care team, including the physician, to execute an appropriate and safe transition between levels of care. This checklist is being distributed to all health care settings across the continuum and directed to interdisciplinary team members, including but not limited to, discharge planners, social workers, utilization reviewers, physicians, and case managers.

Physicians can expect that discharge planners and care team members in all care delivery settings will be actively seeking more information about patients and their needs in order to improve and expedite safe patient discharges. We ask that you share this letter and the checklist with your membership. Staff are available to discuss details about the initiative and the checklist with your members. (Please contact Anna Colello at (518)-402-5733 or dcpwg@health.state.ny.us for additional information about various Department of Health programs; contact Michael Paris at (518)-473-3387 or comments@aging.state.ny.us for State Office of Aging services).

Thank you for your time and attention.


David Wollner
Director, Office of Health Systems Management
New York State Department of Health

Neal Lane
New York State Office for the Aging

| "Discharge Planners Checklist" |