The facility has a high number of discharges to the community every month, and the director of nursing services (DNS) feels the discharge process is a good one, as she has received no complaints from residents or staff. However, a review of the facility’s Quality Measures (QMs) tells a different story. The facility is above threshold for several measures relating to discharge and rehospitalization. While the DNS knows she needs to address this, she doesn’t know where to begin. Does this scenario sound familiar? This article will review the key elements of a strong discharge process and share tips the DNS can use to assess the current process and educate staff.
Why Discharge Planning is Important
Of the many reasons that discharge planning is important, the foremost is that it reduces the risk of adverse events occurring post-discharge. Inadequate knowledge, equipment, communication, or preparation can all contribute to adverse events after resident discharge. The discharge planning process is necessary to ensure residents have all the resources, equipment, and medications they need for success when they return home.
Next, discharge planning is important because the Centers for Medicare & Medicaid Services (CMS) requires it. A facility will receive a citation for non-compliance if it fails to implement a discharge plan that meets the requirements outlined in Appendix PP of the State Operations Manual (SOM).
Discharge planning is also vital to reduce readmissions to the hospital from skilled nursing facilities (SNFs). Planning for resident needs at home and ensuring the resident or his or her representative understands all discharge instructions can significantly reduce the chances of a hospital readmission.
Due to the high cost of the consequences of poor-quality discharge planning, CMS has established QMs that address readmissions. These QMs incentivize nursing home providers to deliver care that prevents readmissions and safely discharges a resident back to the community. These incentive programs include:
- The SNF Value-Based Purchasing (VBP) program uses the SNF 30-Day All-Cause Readmission Measure (SNFRM; NQF #2510). CMS states on the SNF VBP Program’s Hospital Readmission Measure page, “The SNFRM measures the rate of all-cause, unplanned hospital readmissions for SNF residents within 30 days of discharge from a prior hospital stay.”
- The SNF Quality Reporting Program (QRP) also measures the rate of successful return home or to the community (Discharge to Community), as well as potentially preventable 30-day post discharge readmissions.
- The Five-Star Quality Rating System uses several QMs related to the discharge process, including:
- Discharge Function Score (also a SNF QRP measure and future VBP measure)
- Percent of Short-Stay Residents Who Have Had an Outpatient Emergency Department Visit
- Percent of Short-Stay Residents Who Were Re-Hospitalized After a Nursing Home Admission
- Discharge to Community (also a SNF QRP measure and future VBP measure)
Steps to the Discharge Process
The discharge process is a multi-step process that should begin upon admission and guide the resident’s stay. Many steps, tailored to the resident’s needs, must occur prior to the day of discharge to ensure safety afterwards. For example, prior to the day of discharge, staff should:
- Assess the discharge destination to ensure resident safety.
- Ensure all entities involved in caring for the resident communicate with one another and understand the resident’s goals and progress toward those goals.
- Contact the home health agency of the resident’s choice for durable medical equipment and/or care visits.
- Educate the resident and his or her caregiver regarding treatments that will occur at home and have them perform a return demonstration.
- Educate the resident and his or her caregiver regarding medications, including but not limited to instructions on the needed dose, how to administer, and how often.
The day of discharge can be busy, but a solid process helps to ensure the facility performs all essential steps. When the facility gives the resident written discharge instructions, staff should confirm they are legible and include areas such as:
- Medications – Review with the resident all medications, along with when and how to take them. Ask the resident or caregiver to repeat the instructions back to ensure they understand. Staff should ensure they provide a copy of and discuss with the resident all prescriptions needed for home use. The facility may also wish to send a limited supply of medications home until the resident can obtain more. Answer all questions the resident or caregiver has.
- Treatments – Review with the resident when and how treatments should occur at home. Ensure the resident has the supplies to complete the treatments. As with medications, staff should confirm understanding by having the resident or caregiver repeat the instructions back and should answer all questions they may have.
- Appointments – Ensure that the discharge instructions include all follow-up appointments. Staff should discuss appointments with the resident and caregiver to ensure they understand the appointments schedule. If any further arrangements or changes are necessary, direct them to the tasks that require action to ensure the resident keeps the follow-up appointments.
- Contact Information – Include the phone number of the facility so that the resident or caregiver can call if they have any questions once they are home.
- Equipment – Often, residents will need a hospital bed or other equipment when they go home. Although social services or other staff members may have ordered this equipment prior to the day of discharge, it’s important to ensure that all equipment needed is at the resident’s home. If delivery has not occurred yet, at the very least, staff should include in the written instructions a date and time for when equipment will arrive.
Follow-up calls should always be part of the discharge process. It’s important to check in with the resident or caregiver once he or she has settled in at home to see how they are doing, if they are safe, and if they have any further questions. The facility can assist with any issues they may have, such as if equipment has not been delivered or a vendor has not visited as scheduled. These calls often help the resident to succeed at home by correcting any issues before they become too big for the resident to handle.
Staff Education
Facility staff, particularly licensed nurses, must understand the steps of the discharge process and their role in that process. Key areas for education regarding the discharge process should include:
- Assessment upon admission to identify resident needs that must be addressed before the resident can be discharged, such as resident education, rehabilitation, and caregiver support and education
- Regular evaluation of needs to ensure the facility is following the resident’s goals and preferences for discharge
- Identification of post-discharge needs such as equipment, modifications to home, therapy or other support services
- A process for how to provide discharge instructions that the resident or their representative will understand
- Steps to take if the resident or their representative wants to discharge to an unsafe environment
AAPACN has developed the Discharge Planning for Licensed Staff in-service education to assist the DNS with training.
Auditing the Discharge Process
Nurses assess residents to gather data to relay to a physician for a diagnosis or to determine a nursing diagnosis. Once nurses identify the problem, they can implement a treatment. This is the same process the DNS should use when reviewing a system such as the discharge process.
When auditing the discharge process, the DNSshould review medical records of those residents already discharged, as well as those who will be discharged soon. The DNS should conduct observations to ensure that:
- Each resident is receiving appropriate care
- The facility is meeting the standard of care
- Staff are following the facility’s policies and procedures
To determine the above, during the review of the medical records and observations, the DNS may wish to ask these questions:
- Did staff assess the discharge destination to ensure the resident’s safety post-discharge?
- Did the facility obtain a physician’s order for discharge?
- Did staff schedule follow-up appointments?
- Is the resident or their representative aware of the follow-up appointments?
- Did the facility contact the resident’s home health, hospice agency, or other entity of choice and schedule the first visit?
- Did the facility provide the resident’s health information to the receiving entity?
- Did staff order the durable medical equipment the resident needed at home?
- Did staff educate the resident or their representative regarding treatments to be completed at home, with return demonstration to ensure understanding?
- Did staff educate the resident or their representative on medications? Do they understand how to take medication and what side effects to be aware of?
- Was a 3-day supply of medication available for the resident upon discharge?
- Did the facility provide written discharge instructions to the resident or resident’s representative?
- Did the facility follow its policy regarding the provision of medications to take home?
- Did the resident or their representative receive prescriptions for medications and treatments?
- Did staff provide to the resident or resident’s representative the follow-up appointment time and place and phone numbers for contacts regarding the appointments?
- If the resident left against medical advice (AMA), did the facility follow its protocol?
- Does the medical record contain discharge documentation per facility policy?
- Did staff conduct and document a head-to-toe assessment including vital signs conducted? If the resident didn’t give permission, is that choice documented?
- Did staff make a post-discharge phone call to the resident to ensure safety and to check if he or she had any questions?
If these questions reveal any areas of non-compliance, correct the problem to ensure it does not occur in the future.
A comprehensive system review includes an evaluation of the correlating policy and procedure. This is especially important when staff members are not following the policy or procedure. If the review identifies a deficient practice, such as pre-discharge resident training not occurring, review that portion of the policy and procedure first. Consider the following questions:
- Is it consistent with current regulatory requirements?
- What departure from the policy and procedure led to the issue?
- Why was the policy or procedure not followed?
There are various reasons why staff may not follow a policy or procedure, such as it not being current, being hard to understand, or a lack of resources to follow it.
After conducting an assessment of the system, the DNS and his or her team should review the data for any trends or concerns. Conduct a root cause analysis, then implement sustainable changes to ensure the discharge process is a strong one. The ultimate goal is to ensure residents’ safety once they are home. A strong discharge planning process charts the path towards meeting this goal.
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