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5 Things You Need Now to Improve Discharge Planning

Acute Care November 24, 2020

One of the most important duties nurses have is to prepare patients for discharge.

Teaching patients about their conditions, medications, self-care strategies and the importance of follow-up care can help patients maintain an optimum level of health and reduce their chances of readmission to the hospital,” says Carole Jakucs, BSN, RN, PHN, in a recent article.

The Agency for Healthcare Research and Quality (AHRQ) found that patients who understand their hospital discharge instructions are 30% less likely to be readmitted than those that don’t.

When done correctly, it also can shorten patient length of stays, reduce CMS penalties and increase hospital revenue.


The fact is that 42% of hospital patients report that they received incomplete discharge instructions. And, 48% of hospital patients—particularly those with limited English proficiency—say they don’t understand their follow-up care plans.

A study conducted through an AHRQ grant found that in older patients, current discharge planning processes fall far short of optimum. “Patient comprehension is addressed in interventions that many hospitals are adopting, but current practice is a long way from where it needs to be,” noted the researchers. “Furthermore, a narrow focus on comprehension may ignore the provider’s responsibility to improve delivery of discharge instructions.”

So, What Should Discharge Planning Encompass? 

There’s been much written in recent years to help guide hospitals in improving and standardizing the discharge planning and care transitions process. The Centers for Medicare and Medicaid Services (CMS) published the Impact Act, intended to give hospitals a standardized set of discharge planning requirements. These included:

  • Develop a discharge plan within 24 hours of admission or registration.
  • Involve patients in the decision-making process regarding their treatment and recovery.
  • Provide discharge instructions to patients who are discharged to their homes.
  • Have a medication reconciliation process ready to improve medication management and champion patient safety.
  • For patients who are transferred to another facility, pass on specific medical information to the receiving facility.
  • Establish a post-discharge follow-up process.

In addition to these requirements, hospitals are now expected to collect and report data to improve the overall care delivery, with a special emphasis placed on the discharge process.

The Agency for Healthcare Research and Quality acknowledged that when patients are engaged in their healthcare, it often results in improvements to quality of care and patient safety. It created a best practice discharge planning checklist, using the acronym IDEAL.

Despite all of that focus at the regulatory and thought-leadership levels, and hospitals’ best efforts to apply best practices, unplanned readmissions still cost hospitals in America $15-$20 billion per year. So, what do we need to do to truly begin improving patient care transitions and discharge readiness? Here are five steps to take now.


Clinicians agree that from the moment a patient enters the hospital, it’s critical to begin preparing them for a safe discharge. But manual processes just aren’t working.

Automating the discharge planning process is the key to ensuring the hospital consistently adheres to it. One of the best ways to enhance the patient’s discharge readiness is by automating and integrating the admission discharge and transfer (ADT) with the interactive patient engagement platform. The integrated plan can then follow the patient from admission through post-acute care, whether at home or in another setting.

Part of the hospital discharge planning automated process should be setting a clinical management plan within 24 hours of admission. Include automated cues and reminders to ensure the nursing team creates a complete picture of the patient’s situation, from prior to their hospital admission, through their hospital stay and their return to home.

As part of that patient profile, address the patient’s social determinants of health. Does the patient have transportation to the pharmacy and follow-up appointments? Can the patient read and understand prescriptions and how to use them? Does the patient have access to healthy meals? And so on.


It’s not just patients that need to be engaged with their care. Their families must be involved with the process as well.

Discharge isn’t a one-time event. Rather it’s a process that happens throughout the hospital stay and continues afterward. It’s critical that family members are included at all points of the discharge planning. The hospital must identify which family members or friends will be helping to manage the post-acute care and then bring them into the conversation.

According to AHRQ, best practices include:

  • Determine the patient and family goals at admission and track your progress daily.
  • Involve the family in nurse bedside shift reports or rounds.
  • Share a written list of medicines every morning.
  • Review medicines at each administration, answering what it’s for, its side effects, and proper administration.
  • Encourage the family to be involved in care practices at the hospital so that they’re prepared for home.

There are other ways to include family members as full partners, namely, by providing them with informative and understandable content. Few of us want to be handed stacks of reading material to absorb and keep up with. And studies show that patients—and we can assume family members too—retain virtually no medical information shared with them verbally.

What’s the answer? Provide content in engaging, interactive, understandable, readily accessible formats. In other words, provide health education in the same way we absorb other content in our lives, whether it is streaming videos or 24/7 TV.

Videos and digital materials are more engaging, have greater accessibility, can be replayed and shared, and are in a format that the modern consumer prefers.

Hospitals that have embraced technological solutions to increase engagement and involve both the patient and the family have outperformed national averages in HCAHPs Improvement, in a variety of categories, including: responsiveness (8.47 to 4.48), recommendation (5.63% to 1.41%), overall rating (8.96% to 4.29%).


Nurses juggle a multitude of clinical and non-clinical responsibilities. And with shorter patient stays and heavier patient loads, the nurse’s availability to focus on discharge readiness is challenged.

One key to ensuring that every patient feels fully prepared for discharge is to leverage technology. Automated and integrated into the EMR and interactive patient platform, nurse-friendly workflows streamline the discharge steps with visual reminders and cues on the patient’s readiness for discharge.

An interactive discharge readiness checklist on the patient room TV gives both the nurse and patient a visual reminder of the steps completed and those yet to be completed before the patient is ready for discharge. This includes checkpoints to note that the patient has viewed all their health education videos; that the patient has watched medication videos or read about them on the TV screen; that the patient has ordered take-home medications, if needed, from the hospital pharmacy; and so on. As the nurse rounds, each of these steps can be reviewed by visually walking the patient through their interactive discharge checklist on the TV.


Rigorous documentation is one of the most important aspects of IDEAL discharge planning. To make the best decisions possible, care teams need a wealth of information, including:

  • What medicines patients were on before they were hospitalized
  • A patient’s complete medical history
  • Patient’s care diagnostic and assessments
  • Patient’s medication treatment history and reconciliation

Integrating the interactive patient’s discharge readiness checklist into the EMR platform ensures continuity of care from one nursing shift to the next, and from one care setting to the next.

Many post-acute providers complain that they receive patients with little, or at least incomplete, information that makes the care transition more challenging.

What do skilled nursing and short-term rehab facilities need? Holly Harmon, senior director of clinical services at the American Health Care Association, says, “Is there a complete story for the person prior to their hospital admit, during their hospital stay and goals for after hospital stay care?” In addition, she says, post-acute care facilities need to know the patient’s complete medical history, assessments, and medication treatment history and reconciliation and any gaps in information.


Patient risk assessment is an important part of the discharge process. Some patients are fine to be discharged at home, while others would benefit from post-acute care. Deciphering which patient needs post-acute care, and where, is made easier with the help of automation.

Today, algorithms can analyze key patient data to determine whether or not they need post-acute care, and to help patients find the best setting for that care to take place. Using AI to help analyze and identify the best options for a patient is much more effective than simply providing patients with a list of post-acute care settings their insurance provider covers.

As Kathryn Bowles, the van Ameringen Chair in Nursing Excellence, writes:

“[Often] patients and families know nothing about these agencies, and they don’t even understand why you’re offering them these options. And as a result, many patients are going without the post-acute care their providers say they need. We’ve seen almost 30 percent of patients refuse the recommended post-acute care services, and then those patients go on to be readmitted at rates much higher than patients who did accept the services.”

Bowles goes on to say that the best solution for this problem is bedside tools that outline a patient’s post-acute care options, and provides a list of care quality scores and other elements a patient will need to evaluate the ideal care setting and choose the best option for them.

Such technologies can help with:

  • Automating care transitions
  • Providing informed post-acute choices via AI predictive analytics
  • Extending the clinical care model beyond the hospital stay
  • Improving patient engagement and satisfaction
  • Reducing readmissions and related costs


Hospital discharge planning is a vital aspect of ensuring that your patients leave your hospital healthy and then remain so. Automating and integrating the discharge planning readiness process throughout the patient’s stay has proven to help hospitals increase HCAHPS scores and reduce readmissions.

Hospitals using an automated, interactive approach to preparing patients for a safe discharge have seen impressive outcomes. Allen hospitals using interactive technology have achieved a 15% improvement in HCAHPS medication communication rating, 9% improvement in discharge readiness ratings, 15% increase in care transitions, and 13% increase in nurse communication ratings.

Learn how your hospital can transform the care transitions process and your patients’ discharge readiness. Contact us.



  1. NCBI. Reducing Hospital Readmission: Current Strategies and Future Directions.
  2. Transitions of Care.
  3. NCBI. Patient understanding of discharge instructions in the emergency department: do different patients need different approaches?
  4. NCBI. Language Barriers and Understanding of Hospital Discharge Instructions.
  5. NCBI. Hospital Discharge Instructions: Comprehension and Compliance Among Older Adults.
  6. Federal Register. Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, etc.
  7. AHRQ. Care Transitions from Hospital to Home: IDEAL Discharge Planning.
  8. AHRQ. Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning.
  9. Discharge planning starts at admission.
  10. NCBI. Enhancing Patient Education and Medication Reconciliation Strategies to Reduce Readmission Rates.
  11. AHRQ. Readmissions and Adverse Events After Discharge.
  12. Health IT Gov. Improving Hospital Transitions and Care Coordination Using Automated Admission, Discharge and Transfer Alerts.
  13. PharMerica. The 5 things every SNF should know about discharge planning.
  14. Engage with Sentrics. Sentrics Customers Outperform National Averages in HCAHPS Improvement.
  15. Nursing Satisfaction Impacts Patient Outcomes, Mortality.
  16. Patient Engagement HIT. Using Health IT to Support Discharge Planning, Post-Acute Care. Cancer Institute. Follow-up Care.

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