Discharge Planning: A Critical Component of the Continuum of Care

By October 30, 2020 January 27th, 2021 No Comments

In many ways, for those responsible for the care of patients, discharge planning is everything.

Expert care planning reduces adverse events and preventable readmissions and creates an overall better patient experience. Hospital systems and physician groups that work within value-based care models have an obligation to transition patients successfully. Discharge planning is a critical component of the care continuum and requires a strategy for success.

October 30, 2020

Our experts, Dana Strauss and Andrea Rizik, came together to provide their 50-years combined healthcare expertise on the subject. Strauss is Integrated Care Solutions’ (ICS) Vice President of Partner Engagement and a Doctor of Physical Therapy whose clinical career experience and business development background influenced her career shift to value-based care programs. She believes the healthcare system can meet everyone’s needs better. Her passion is advocating for optimal patient experiences and outcomes wherever an individual is on the spectrum of wellness, illness, injury, or chronic-care. 

Rizik is ICS’ Vice President of Clinical Integration and Clinical Operations and a Registered Nurse. As a post-acute clinical operations specialist, she has developed disease-specific specialty programs with clinical care pathways and has overseen case management and care transitions across multiple organizations. Her clinical integration expertise was honed through comprehensive leadership roles connecting patients to the most appropriate setting and tightly managing care, leading to improved quality and optimal outcomes.

Discharge Planning as Transitional Care 
According to Strauss and Rizik, the term “discharge planning” in overall healthcare management should more appropriately be considered transitional care or transitional planning. 

“A patient you’re managing is never truly discharged,” Strauss said. “You have to take into consideration that you’re not fully releasing the patient. Patients are transitioned from one place to the next. Your responsibility is to ensure the quality of that handoff to whoever will be responsible for the next level of care and through the community setting. The value of a post-acute site of care is not just in the care provided while a patient is on-site, but the long term success of that patient after transition.” 

When we think of discharge planning, we think of it as a process for patients on their way out of a care setting. It’s more than that—it’s dynamic and evolving and customized for every patient. Many care settings have their own processes for discharge planning, but not all are created equal. 

“Discharge planning has to begin immediately upon admission,” Rizik said. ”It’s a misconception that hospitals or skilled-nursing facilities feel like they don’t have to address discharge planning until patients are ‘ready to go home.’ Our mantra is that ‘discharge planning starts upon admission.’ Every aspect of the patient’s needs—physical, social, and emotional—are taken into account through the transition. Very early discharge planning helps in setting realistic expectations, aligning on goals based on the medical and therapy prognosis, and establishing an approximate date of transition to the next level of care.” 

The Impact Act of 2014 laid out a roadmap for seamless and safe patient transitions across care settings. In practicality, this happens to varying degrees of success. It is also imperative that clinical teams that manage the patient at every care setting review prior transitional documents. Strauss and Rizik also strongly encourage warm hand-offs between care settings, both to highlight areas of immediate concern (e.g., outstanding bloodwork), and to make sure the patient’s care plan translates accurately to the next site of care.  

In 2016, the Centers for Medicare & Medicaid Services (CMS) set out to provide a clear framework for managing the individuals in skilled nursing facilities (SNF) across the country. According to this final rule, improved care planning included “discharge planning for all residents with involvement of the facility’s interdisciplinary team and consideration of the caregiver’s capacity, giving residents information they need for follow-up after discharge, and ensuring that instructions are transmitted to any receiving facilities or services.”

SNFs aren’t the only care setting CMS has targeted for updates to transition planning. Acute care hospitals were issued a final rule in 2019 that empowered patients to make informed decisions about their care as they are transitioned from acute care into post-acute care. Strauss and Rizik note that this interoperability directive by CMS should be consistent because of best practice guidelines, but that this rule was needed to enforce the imperative of high-quality collaboration with patients and families.

What Doctors Need to Know About the Discharge Planning Process
No longer can physicians afford not to know where their patients are in the continuum of care as they take on the risk, and they need someone, like ICS’ clinical staff, to manage that. Here are five things doctors need to know about the discharge planning process from hospitals and SNFs.

  • Hospitals are incentivized to transition patients efficiently and remove barriers to discharge, while SNFs’ payment model, which is per diem, may encourage longer stays than medically necessary.
  • Patients’ immobility during hospital and post-acute stays can be a primary reason for transition challenges and often lead to complications. Hospital and SNF mobility programs are not pervasive. Still, their presence is best practice and can lead to better outcomes, reduced risk of complications, and limit time the patient needs to be in an alternate care setting from home.
  • Strong transitions can reduce readmission risk from inpatient settings to the primary care physician. Physicians should expect their partnering hospitals and SNFs to provide discharge summaries, updated medication lists, and set up a prompt follow-up appointment.
  • SNF formularies can result in changes to patients’ long term medications and treatments, resulting in patient confusion if not well-reconciled.
  • Having strong and receptive relationships with your local home health agencies can mean the difference between a successful transition home and one with complications.  Home health is an ally for your patients’ successful management after inpatient stays.

Discharge Planning as Part of a Care Coordination Strategy
To overcome many of these challenges, Strauss suggests that discharge planning becomes part of the broader care coordination strategy. An example of such an evolution is how hospitals are moving away from case management departments and creating care coordination departments.

“Discharge planning,” she said, “can be thought of as the process of identifying patient/care partner options for transitioning out of the acute care hospital, identifying safety and medical concerns for the transition and the patient’s long term success, ensuring loss of mobility at the hospital doesn’t limit choices of settings, and communicating with the patient/care partner about the best choice of setting and best provider to meet that need.”

As a case in point, ICS helps organizations improve community care coordination and drive the transformation to value-based healthcare with the mission of managing 90-day timelines for post-acute care. 

“An important part of the transition to home is ensuring patients are reconnected to their community medical provider. This includes a discharge summary being sent, as well as the discharge medications and referrals to community agencies,” Rizik said. “We also make sure inpatient sites of care take the extra step before discharge to schedule their first follow-up appointment within one week. In a sense, we serve as an advocate for the patient through different levels of care.”

A Discharge Planning Checklist for Best Practices
Simply put, successful discharge planning means thinking first about how your care setting can facilitate positive long-term patient outcomes. The following is a discharge planning checklist to help guide the overall care coordination strategy. 

  1. Is the patient stable, safe, and improving at the next level of care? 
  2. Have realistic short- and long-term expectations been established in cooperation with the patient and care partner? 
  3. Have readmission risks been addressed?
  4. Are high-quality post-acute care choices being made with the discharge planning team’s involvement?
  5. Has the likely next-level-of-care setting been identified based on a comprehensive consideration of relevant factors?
  6. Has the community physician been identified and made aware of the patient’s presence in the facility? Is it necessary to contact that provider for background information about the patient?

Successful transitions are an essential component of long-term success for a patient population. ICS’s role is to support patients and guide physicians and health systems through the value-based process. If your practice is transitioning from a hospitalization and healthcare delivery system to community-based care, ICS can help you proactively manage patients’ clinical and care coordination needs. We also provide advisory services to health systems, post-acute providers, and physicians. 

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ICS helps organizations improve community care coordination and drive the transformation to value-based care. Learn more about how ICS delivers results for organizations by putting patients first. Call us today: 860-622-7645.


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