Discharge planning involves a coordinated effort among patients/residents, caregiving professionals, family members, and community supports. It is intended to smooth the transition from facility care to a home setting or alternate facility.
Because of the number and variety of activities that must be carried out, and the number of people and disciplines involved, quality improvement initiatives for discharge planning strongly recommend the use of checklists and tools to assure that all needs have been addressed. The purpose of this toolkit is to provide practical information and resources to facilitate and support facility efforts to meet discharge planning needs.
Discharge Planning Toolkit (pdf)
Preparing Residents For Discharge (11:58) - recorded webinar
DISCHARGE PLANNING TOOLKIT TABLE OF CONTENTS
SECTION I: STAFF RESOURCES
New Requirements for Discharge Planning
Includes information on the new Mega-Rule requirements for Discharge Planning that became effective 11/28/17.
Procedure/Checklist for Discharge Planning
Tool for monitoring completion of new Mega-Rule requirements
List of actions to consider prior to and on the day of discharge
Assessment of Post-Discharge Needs
Checklist of items to include in a discharge plan
Listing of factors for increased risk of hospital readmission.
Care plan that can be used as is, or incorporated into facility’s care plan format.
Being Sensitive to Cultural Differences
Factors to consider in respect to individuals' beliefs and practices; web resources
to gain insights about specific groups
Resident and Caregiver Education
Review of items which need to be considered for effective education on post-discharge care.
Discharge Planning: Diabetic Management Checklist
Listing to ensure inclusion of essential information needed for disease management.
Blank template
Medication Administration Schedule
Blank Template
Discharge Summary Suggested Content
General guideline for discharge documentation.
Blank form that can be completed and copied for resident/family/continuing care providers.
Online Resources for Discharge Planning/Preparation
Listing of web resources with useful information for staff, resident, or caregiver during the process of discharge planning.
SECTION II: RESIDENT AND CAREGIVER RESOURCES:
Tip sheets for resident/caregiver:
Tips for Preventing Infections
When to Notify A Medical Provider
For Family Members: Recognizing Potential Problems
How Advanced Age Can Affect Self-Care
Listing of online websites to assist with resident and caregiver education for:
Health Conditions
Advance Directives/MOLST
Alzheimer's Disease
Anticoagulant Therapy
Arthritis
Chronic Obstructive Pulmonary Disease (COPD)
Congestive Heart Failure
Cultural Differences
Diabetes Mellitus
Fall Prevention
High Blood Pressure (Hypertension)
Joint Replacement Surgery
Low Vision
Medication Education
Oxygen Safety
Pneumonia
Stroke
Substance Abuse
Urinary Incontinence