Coordinates nursing discharge planning with medication teaching, follow-up scheduling, and resource coordination. Use when planning discharge, coordinating post-discharge care, or documenting discharge teaching.
Coordinates nursing discharge planning with medication teaching, follow-up scheduling, and resource coordination. Use when planning discharge, coordinating post-discharge care, or documenting discharge teaching.
Discharge planning is a CMS Condition of Participation (§482.43) requiring hospitals to have a discharge planning process that applies to all patients. Effective discharge planning reduces 30-day readmissions — a CMS quality metric under the Hospital Readmissions Reduction Program (HRRP) that imposes payment penalties for excess readmissions for heart failure, acute MI, pneumonia, COPD, THA/TKA, and CABG. The Joint Commission requires a coordinated, patient-centered discharge process. ANA Standard 5 (Implementation) includes coordination of care and Standard 5B includes health teaching as core components. HCAHPS discharge information domains directly affect hospital reimbursement under Value-Based Purchasing. Poor discharge planning contributes to medication errors at transitions (an estimated 60% of medication errors occur at care transitions), patient confusion, missed follow-up, and preventable readmissions.
Checkpoint A — Intake Verification
Required Patient Information
Current medical diagnoses and problem list
Current functional status: mobility, ADL independence, cognitive function
Discharge disposition: home, home with services, SNF, LTACH, inpatient rehab, hospice
Social determinants of health: housing stability, transportation access, food security, caregiver availability, insurance status
Patient/family goals and preferences for post-discharge care
Advance directives and code status (relevant for skilled nursing or hospice transitions)
Language, literacy, and cultural considerations
Required Clinical Information
Discharge medication list (reconciled against admission medications)
Pending diagnostic results that may affect discharge plan
LACE Index score or institutional readmission risk tool completed (Length of stay, Acuity of admission, Comorbidities, Emergency department visits in prior 6 months)
Patients with inadequate social support or housing instability
Patients with readmission risk factors
Initiate interdisciplinary discharge planning team involvement: case management, social work, physical therapy, occupational therapy, dietitian, pharmacy as appropriate
Set an estimated discharge date (EDD) and communicate to patient/family and care team
Document the initial discharge planning assessment in the medical record
Step 2 — Conduct Medication Reconciliation for Discharge
Compare the current inpatient medication list against the pre-admission medication list
Identify medications that were: continued, modified (dose/frequency change), added (new), or discontinued during the hospitalization
Resolve discrepancies: For each changed medication, document the clinical rationale
Verify the patient/caregiver can obtain all discharge medications:
Insurance formulary coverage
Pharmacy access
Cost barriers (coordinate with social work or pharmacy for patient assistance programs)
Generate the discharge medication list in plain language with:
Medication name (generic and brand)
Purpose
Dose, frequency, route
Special instructions (take with food, avoid grapefruit, etc.)
Warning signs: Specific symptoms requiring emergency care vs. provider contact
Use condition-specific red flags (e.g., CHF: weight gain > 2 lbs/day, worsening SOB; surgical: fever > 101.5°F, wound drainage change)
Equipment use: Demonstrate any DME (oxygen, glucometer, wound vac, etc.)
Document teach-back results for each topic. Reference managing-patient-education skill for detailed teaching methodology.
Step 4 — Coordinate Post-Discharge Services
Home health referral: Submit orders for skilled nursing, physical therapy, occupational therapy, speech therapy, home health aide as indicated; ensure referral includes specific visit frequency and duration
SNF/LTACH/Rehab placement: Coordinate with case management; ensure medical records transfer; confirm bed availability; arrange transportation
DME coordination: Order equipment, confirm delivery date/time, arrange for patient/caregiver training
Outpatient services: Schedule follow-up appointments before discharge; PCP follow-up within 7 days (within 48 hours for high-risk patients)
Community resources: Connect patient/family with disease-specific support groups, nutrition programs, transportation services, pharmacy assistance programs
Caregiver support: Assess caregiver burden; provide caregiver education and respite care resources
Step 5 — Execute Day-of-Discharge Protocol
Confirm all discharge orders are complete and signed
Verify discharge medication prescriptions are transmitted to pharmacy or provided to patient
Perform final medication reconciliation at discharge — compare what patient received inpatient against discharge orders
Complete all discharge education with documented teach-back
Provide written discharge instructions: medication list, follow-up appointments, activity restrictions, dietary instructions, warning signs, emergency contact numbers
Ensure patient has follow-up appointment confirmed (not just "call to schedule")
Arrange transportation
Remove IV access, urinary catheter, and other devices not needed post-discharge
Perform final assessment: vital signs, pain assessment, ambulation status
Escort patient to vehicle per institutional policy
Step 6 — Document the Discharge
Discharge summary note: date/time, condition at discharge, mode of transport, accompanied by whom
Discharge medication list: complete reconciled list with patient/pharmacy copies
Discharge instructions: all topics covered with teach-back results documented
Follow-up plan: appointment dates, provider names, pending results with follow-up plan
Referrals placed: home health, DME, outpatient services with confirmation
Advance directive status: confirmed and communicated to receiving facility if applicable
Checkpoint B — Discharge Readiness Review
Patient Readiness
Patient/caregiver can verbalize diagnosis, medication regimen, warning signs (teach-back confirmed)
Patient/caregiver can demonstrate any required skills (wound care, injection, equipment use)
Patient has transportation arranged
Patient has medications or prescriptions in hand
Patient has written discharge instructions in preferred language
System Readiness
All discharge orders complete and signed
Medication reconciliation completed with discrepancies resolved
Follow-up appointments confirmed (not just recommended)
Home health/SNF referral submitted and confirmed
DME ordered and delivery confirmed
Discharge summary dictated/completed for PCP communication
Transition record sent to receiving provider/facility per CMS requirements
Quality Audit
Discharge planning initiated within 24 hours of admission per CMS CoP §482.43
Readmission risk screening completed with appropriate interventions for high-risk patients
Medication reconciliation performed at discharge with discrepancies resolved and documented
Teach-back documented for all required discharge education topics
Follow-up appointments scheduled before discharge (PCP within 7 days for general; 48 hours for high-risk)
Written discharge instructions provided in patient's preferred language at appropriate literacy level
Condition-specific warning signs included in written instructions
HCAHPS discharge information domains addressed: understanding of care at home, understanding of medication purpose
30-day readmission rates tracked per CMS HRRP conditions
Discharge process compliant with CMS CoP §482.43, Joint Commission standards, and ANA Standards 5 and 5B
Guidelines
CMS CoP §482.43: Hospitals must have a discharge planning process; evaluate patients for discharge needs; develop discharge plans; arrange for post-hospital services
CMS HRRP: Hospital Readmissions Reduction Program penalizes hospitals with excess 30-day readmissions for specified conditions
Joint Commission: Transition of care standards require coordinated discharge with patient engagement, medication management, and follow-up
ANA Standards: Standard 5 (Implementation) includes coordination of care; Standard 5B (Health Teaching) requires education for self-management
HCAHPS: Discharge information domain questions directly affect hospital reimbursement
Medication reconciliation: Joint Commission NPSG.03.06.01 requires medication reconciliation at every transition of care
Health literacy: Discharge instructions must be at or below 6th-grade reading level; use teach-back to verify comprehension
Scope of practice: RN coordinates discharge planning, performs medication reconciliation, delivers and evaluates discharge education; case management arranges post-acute services; social work addresses psychosocial barriers; pharmacy reviews medication reconciliation for high-risk regimens
Post-discharge follow-up: Evidence supports follow-up phone calls within 48–72 hours of discharge to reduce readmissions; include medication review, symptom assessment, and appointment confirmation
