Discharge Planning Whitepaper

About the Discharge Planning White Paper

Discharge planning, a type of transition of care, actually begins the moment a patient enters a healthcare program or facility regardless of the service or attention initially requested or required. The monitoring and oversight of discharge planning may continue through several transitions, levels, or locations of care including the patient’s home and, in some cases, for their entire life.

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Discharge plans must be highly individualized based on the patient’s specific needs at any given time during the treatment process and the most fitting and available resources. It is adjusted or revised as needed based on the patient’s progress or decline. Discharge plans can be prepared by any number of professionals involved in the patient’s care, but they are usually completed by a social worker, case manager, or nurse prior to the physician or primary caregiver in charge of the case releasing the patient from additional care or recommending transfer to a step-down, less restrictive facility or caregiver.

Although usually associated with hospitals and other medical facilities, discharge planning occurs in many systems of care. Corrections, foster care, schools, domestic violence and child abuse shelters, and mental health and substance abuse treatment centers and residential facilities all develop discharge plans for their clients who are ready for a different level of care and support in a new environment. Not surprisingly, participants in the corrections, foster care, and other municipal or crisis systems frequently have mental health and substance abuse issues. Behavioral healthcare providers are often the first step in the transition of care for these clients when they leave those systems and often assume the role of discharge planner or case manager.

Effective discharge planning is a team approach and is a comprehensive and highly coordinated process designed to ensure continuity of care. The basic principles include:

  • Evaluation – Understanding the patient’s current state of health and their need for specific ongoing treatment or therapy.
  • Preparation – Planning for the recommended transition and approved admission to another facility, location, or caregiver; procuring HIPAA-required releases of information from the patient.
  • Communication – With the patient and their family, advocate(s) and others involved or impacted by the recommended transition.
  • Education – For the patient and their support network regarding the recommended transition and may include training for administering specific types of care.
  • Verification – Confirming orders for treatment plans, medication schedules, and other components of recommended care as well as insurance coverage or other financial support.
  • Referral – Identifying professional inpatient/outpatient facilities and providers or other community resources (housing, employment, transportation, meals, social and/or spiritual, etc.) to support the transition.
  • Follow-Up – Ensuring the transition occurred as recommended, appointments are kept, prescriptions are filled, and caregivers are following physician’s orders.

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