Nursing Notes

April 9, 2011

Prevent Readmissions With Discharge Planning

With The Joint Commission looking at “revolving door” admissions, it is time for everyone to get on board and start working to prevent readmissions.  Being readmitted benefits no one.  The patient feels like their health has become unmanageable and they are frightened.  The family becomes convinced that they cannot handle the needs of the patient safely.  The hospital, once a safe haven, becomes a scary place.

We have to work “better” not harder at discharge planning.  We need to be looking at the patients’ needs and desires as much as possible.  Just getting patients out of the hospital is no longer acceptable.

The article below is long, but well worth your time.  Only part of it is below, so please do click over to finish reading.  This is from one of my favorite sites, Health Leaders Media, where you will find many other great articles dealing with various issues in today’s nursing.


Rebecca Hendren, for HealthLeaders Media , April 5, 2011


Discharge planning is a process that should begin as soon as patients are admitted to the hospital. In a perfect world, healthcare team members, patients, and families communicate and work together to move patients quickly and safely to home or the next level of care.

In reality, discharge planning can be fractious. Older adult patients and their families face many choices about where to go and often disagree on the best course of care. Communication among caregivers can be far from ideal and communication between patients and families can be fraught with disagreements.

As hospitals battle readmission rates, more attention is being paid to discharge planning. Lori Popejoy, Phd, APRN, GCNS-BC, assistant professor in the Sinclair School of Nursing at the University of Missouri, has been studying the discharge planning process around older adults and recommends hospitals pay more attention to the decision-making process with these patients.

Popejoy, who has years of experience with care of the older adult before entering academia, recently published a study, “Complexity of Family Caregiving and Discharge Planning,” in the Journal of Family Nursing. I spoke to her about the problems nurses face as they work with older adults and their families, the challenges faced by healthcare providers as they discharge older adults from the hospital, and the healthcare transitions faced by elderly people and their families following hospitalizations.

Popejoy says that our understanding of discharge planning and how patients make decisions is quite simplistic. We usually think about conversations between physicians and their patients or between physicians and families. In reality, dozens of people are involved in any decision. So she examined interactions between healthcare team members, including nurses and social workers, and older adult patients and their families. She wanted to understand how these diverse stakeholders come together to make a single decision about leaving the hospital and where they are going to go. She wanted to understand how much participation in decisions patients and families want the healthcare team to have and what actually happens as decisions unfold.


“Every participant comes to the situation with their own values, their own beliefs, and what they want to get out of it,” says Popejoy. “What stands out for nurses or social workers is their overall concern for patient safety. Their input into the decision making process is to find the most reasonable choice and the safest choice.”

For older patients, most just want to go home. Some recognized they were too weak and were willing to go somewhere else, but for them, it was to be a short-term stay where they could get stronger and then ultimately go home.

For families, safety is important, but also the issue of ‘I want my parent to be able to live the life they want to live,’ says Popejoy. “For a spouse, it’s a whole different ball game—they just want their spouse to go home with them.”

Within child-parent relationships, some want their parents to live with them; others recognize that their lives are too complicated to handle a parent at home who is functionally unable to care for themselves. Some can handle a short-term stay, but not one for the long term.

Popejoy says that hospitals need to figure out who the key players are who can influence decisions. “Listen to older adults and find out what they want, but also listen to the family and what they can do,” she says.

She cautions decision makers are often not available during Monday to Friday business hours. Although most organizations know this, it can be difficult to get good information across the week, not just during traditional work days. Discharge planning and communication may have to be done via conference calls or during off hours.

Another important thing that leaves healthcare teams in difficult positions is the idea of autonomy.


“In the United States, we value autonomy and your independence above all…[read more]

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June 24, 2010

Patient discharge planning receiving more attention

It has always seemed to me that discharge planning was forgotten or simply ignored in the past.  Patients came in, got treated, signed papers and got copies, and they left the hospital.  I always wondered if my patient really understood the correct way to care for themselves at home.  There was a time when home health was available and utilized more, but abuse of that system has curtailed that avenue for the most part.  Home health is still available, just not as readily.

My patients are the mentally ill, so discharge planning is even more important, but at the same time my patients may or may not follow through.  I often worry about patients after they leave the hospital because I know in my heart that they will be back soon.

It’s great to see a push in this industry to have an adequate discharge plan in place and to involve the entire team in this process.  The patients can only win in this situation.

Here’s an article from the Patient Safety Monitor about this topic:

Discharge planning has been an often neglected time in a patient’s hospital stay, which is likely one of the main reasons 20% of patients return to the hospital within 30 days, reports The New York Times. Several new programs have taken root to reverse this trend and ensure that patient care at discharge is a focal point to prevent patients from returning to the hospital.

Two of these programs, Project BOOST (Better Outcomes for Older adults through Safe Transitions) and Care Transitions Intervention, are leading the way. Project BOOST is a creation of the Society for Hospital Medicine and provides interested hospitals with a toolkit of standardized forms to streamline the discharge process. Care Transitions Intervention is out of the University of Colorado Denver’s School of Medicine, with funding from the John A. Hartford Foundation and the Robert Wood Johnson Foundation.

I wrote about the Care Transition Intervention program a couple of years ago in Briefings on Patient Safety. At that time, this project was a newer take on how to manage the handoff process for patients being discharged from the hospital. It also gave rise to the notion of a “transitions coach,” a similar concept to that of the “patient navigator” I posted about last week.

Has your facility taken part in any program that focuses on patient discharge as a means of preventing rehospitalization?


About the Author: Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books, webcasts, and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals ( and manages Patient Safety Monitor (, of which this blog is a part. Contact Heather by e-mailing

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