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.
Preparing Residents For Discharge (11:58) - recorded webinar
DISCHARGE PLANNING TOOLKIT TABLE OF CONTENTS
SECTION I: STAFF RESOURCES
Includes information on the new Mega-Rule requirements for Discharge Planning that became effective 11/28/17.
Tool for monitoring completion of new Mega-Rule requirements
List of actions to consider prior to and on the day of discharge
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.
Factors to consider in respect to individuals' beliefs and practices; web resources
to gain insights about specific groups
Review of items which need to be considered for effective education on post-discharge care.
Listing to ensure inclusion of essential information needed for disease management.
General guideline for discharge documentation.
Blank form that can be completed and copied for resident/family/continuing care providers.
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:
Listing of online websites to assist with resident and caregiver education for:
Chronic Obstructive Pulmonary Disease (COPD)
Congestive Heart Failure
High Blood Pressure (Hypertension)
Joint Replacement Surgery