Discharge Planning should occur throughout the patient's stay. Preparing them for caring for themselves or transitioning to other levels of care requires careful planning and movement along a continuum of "doing for" to "enabling to do for oneself".

• What tools do you use that help you plan for discharge?
• How do you decide when a patient is ready for the next 'phase'?
• How do you engage the patient in the process?

What are your thoughts/ideas about discharge planning?

We use a computer program called Continuum and it is started when the patient is admitted, then it can be updated on a daily basis and we then can watch the pateints progress, or delay due to hold ups in the services etc.

Cynthia

Wow Jaime~ What a great topic (and one that is near and dear to my heart LOL) The issue I am running into with increasing frequency is that staff/floor nurses are not involved in the process at all. This is evidenced by both lack of self involvement (ie not my job, call the case manager) and by lack of being invited- by said case manager- into the process. It is a common occurence in my area for the discharge to be a surprise to both the pt and his/her nurse that day. I represent an business not connected to the hospital where I am primarily based that provides/coordinates discharge to SNFs for rehab etc and often times I am the one that informs the pt they are leaving that day! And these are generally not short LOS I might add!

Didn't mean to highjack your thread and get off topic, so I will conclude with the thought that much more teamwork and interdisciplinariness (is that a word I just made up??) needs to occur. I have observed both a disconnect and a lack of communication that prevents positive outcomes.

DivaRN

In my own practice I have always believe that discharge planning does start from the moment you are in hospital. I have always encouraged my patients to do as much for themselves as they could and naturally help them if need be. On the surgical floor where I used to work we would chuckle when the docs would write "discharge planning" a number of days in advance but it makes sense. The more you get folks ready to go out the door the better they will do afterwards. (In my opinion anyways) For us it was mostly self driven, but we worked closely with community resources and they connected with the patient in the hospital and set up what the patient needed- here in BC (Canada) each patient is entitled to 2 weeks of home care support following their surgery free of charge. I believe most people take that offer I think it is always a good thing to start identifying things from the getgo so that when a patient is dicharged suddenly you have the framework to develop a plan for their safe return home.