• Zwicker D, Picariello G. Discharge planning for the older adult. In: Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice. 2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p. 292-316. [36 references]

This is the current release of the guideline.

This guideline updates a previous version: Discharge planning and home follow-up of elders. In Mezey et al., (Eds). Geriatric nursing protocols for best practice. Springer Publishing Company: New York.

Assessment

• Initiate assessment for discharge planning process at time of admission; continue to reassess throughout hospitalization.
• Focus on those older adults at high risk for poor postdischarge outcomes.
• Assessment should include:
  • Functional status (ability to complete instrumental activities of daily living [IADL] and activities of daily living [ADL] and/or functional independence measure [FIM])
  • Cognitive status (ability to participate in discharge planning process and ability to learn new information)
  • Psychological status of patient, particularly depression screening
  • Patient's perception of self-care ability
  • Physical and psychological capabilities of family/caregiver
  • Knowledge deficits regarding health care needs postdischarge
  • Environmental factors of postdischarge setting
  • Caregiver formal and informal support needs
  • Nine core caregiving processes that ensure family caregivers can provide care smoothly and effectively (see Table 16.3 in the original guideline document)
  • Review of medications and simplification of regimen
  • Prior link to community services

Implementation of the Discharge Plan

• General principles
  • The discharge plan should be tailored to individual patient and family/caregiver needs.
  • Assessment findings will guide intervention strategies.
  • Assessment findings will determine educational and other home health requirements after discharge.
  • Assessment data may predict potential discharge outcomes.
  • Discharge planning should begin at admission due to shortened length of stay and complexities of the population.
  • The discharge plan should be tailored to individual patient and family/caregiver needs.
• Strategies to ensure continuity of care (the 4 Cs: communication, coordination, collaboration, continual reassessment)
  • Communication
    • Communication should occur multidirectionally.
    • Communication should occur between the multidisciplinary team and the patient and family/caregiver.
    • Communication with formal and informal prehospital caregivers should be at admission, ongoing, and prior to discharge.
    • Barriers to communication need to be eliminated.
    • Communication of medical care needs to continue between hospital and community medical provider.
    • Written communication
      • Document assessment findings and home care needs on an interdisciplinary record
      • Summarize hospital course, particularly the following:
        • Include actual or potential sequelae
        • Presentation of unusual symptoms or significant change in status since admission
        • Specific symptom management required (i.e., pain postsurgery and effective management)
        • Medication review and difficulties for patient/family
        • Psychosocial adaptation to stress of illness
        • Anticipated outcomes
        • Advanced directive discussions or decisions
    • Verbal communication of health status and discharge plan with:
      • Patient, family and/or caregiver
      • Primary provider who will follow after discharge
      • Multidisciplinary experts
      • Referrals (e.g., home health agency, other providers of care)
  • Coordination of services/case management
    • Case manager or designated team member should coordinate the multidisciplinary team in the discharge planning process.
    • Case manager will link the person with the most appropriate services postdischarge.
    • Case manager should ascertain understanding of all communication with patient and family/caregiver.
    • Communication should be clear between hospital case manager and home health provider and/or any community resources.
  • Collaboration
    • Multidisciplinary team members should be used for specialized assessments, recommendations, and case conferences.
    • Advanced practice nurse or registered nurse (RN) expert in geriatrics may collaborate with team and provide home follow-up.
    • Designate a case manager or nurse expert in geriatrics to coordinate discharge plan.
    • Family or caregiver can provide information about past experiences, potential barriers, and biopsychosocial needs of the patient.
    • Referrals should occur in-hospital, when possible, to limit transfers from home environment.
  • Continual reassessment
    • The discharge planning process is dynamic, not static.
    • Status of the patient may change rapidly in this population, requiring frequent reassessment.
    • Change in condition should be communicated to all team members.
    • Home care needs change as the assessment is clarified and as the patient status changes.
• The Discharge Planning Process
  • Develop the plan to meet unique needs of each individual patient and family/caregiver.
  • Communication with prehospital formal and informal caregivers should be at admission, ongoing, and prior to discharge.
  • Involve the patient and family throughout discharge planning process.
  • Yield to patient and family wishes and preferences for optimal outcomes.
  • Health teaching, guidance, and counseling (potential areas to address):
    • Gear teaching to specific learning needs of elderly patient.
    • Describe required care related to presenting problem.
    • Describe diet restrictions, and discuss patient preferences.
    • Discuss medication actions and side effects.
    • Discuss symptom management.
    • Define when to call for help.
    • Discuss maintenance of hydration and nutritional status.
    • Delineate signs of a change of condition and whom to report to.
    • Discuss what to report or do in an emergency.
    • Discuss whom to contact in an emergency.
    • Clarify activity level and ability, with a focus on safety and mobility.
    • Discuss and/or clarify advanced directives and care wishes of patient.
    • Verbally review written discharge instructions and follow-up.
  • Treatments and procedures (potential areas to address):
    • Special procedures/care: wound care, tube feedings, hydration etc.
    • Discuss how and when to administer medications.
    • Discuss activities of daily living (ADL) interventions: mobility, transfers, gait training.
  • Surveillance interventions (potential areas to address):
    • Ensure adequate functional status before discharge or refer for appropriate home care needs.
    • Evaluate system-specific physical assessment related to problems or potential problems.
    • Monitor primary problem and potential sequelae.
    • Offer iatrogenesis prevention during hospital course.
    • Functional and cognitive status should be continually monitored.
    • Medication understanding, management capabilities, and side effects should be ascertained.
    • Transportation access and availability should be ensured.
    • Family/caregiver abilities evaluated continually
    • Psychosocial issues that may affect transition need to be assessed.
  • Case management (potential activities of Case Manager)
    • Refer to consultants/providers as needed, preferably while in-hospital.
    • Address questions/concerns from patient, caregiver, and health providers.
    • Provide caregiver with contact numbers of care providers (primary care and home health agency, physical therapy and occupational therapy).
    • Provide follow-up care appointments and contact information.
    • Ascertain access to transportation services.
    • Provide information on other community resources.
    • Assess risk for potential poor discharge outcomes (see Table 16.1 in original guideline document) to ensure appropriate discharge services are utilized.
    • Ensure that caregiver support needs are met.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

• Zwicker D, Picariello G. Discharge planning for the older adult. In: Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice. 2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p. 292-316. [36 references]

Not applicable: The guideline was not adapted from another source.

2003

Hartford Institute for Geriatric Nursing - Academic Institution

The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of The John A. Hartford Foundation Institute for Geriatric Nursing.

Supported by a grant from The John A. Hartford Foundation.

Not stated

Primary Authors: DeAnne Zwicker, MS, APRN, BC; Gloria Picariello, APRN, BC

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Discharge planning and home follow-up of elders. In Mezey et al., (Eds). Geriatric nursing protocols for best practice. Springer Publishing Company: New York.

None available

None available

This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on February 26, 2004.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.