IDEAL Discharge Planning Overview, Process, and Checklist

Evidence for engaging patients and Key elements of IDEAL

families in discharge planning Discharge Planning
Nearly 20 percent of patients experience an adverse
event within 30 days of discharge.1,2 Research shows that
Include the patient and family as full partners in the
discharge planning process.
three-quarters of these could have been prevented
or ameliorated.1 Common post-discharge complications Discuss with the patient and family five key areas to
include adverse drug events, hospital-acquired infections, prevent problems at home:
and procedural complications.1 Many of these 1. Describe what life at home will be like
complications can be attributed to discharge planning 2. Review medications
problems, such as: 3. Highlight warning signs and problems
 Changes or discrepancies in medications before and 4. Explain test results
after discharge3,4 5. Make followup appointments
 Inadequate preparation for patient and family related Educate the patient and family in plain language about
to medications, danger signs, or lifestyle changes3,4,5 the patient’s condition, the discharge process, and
 Disconnect between clinician information-giving and next steps throughout the hospital stay.
patient understanding3 Assess how well doctors and nurses explain the
 Discontinuity between inpatient and outpatient diagnosis, condition, and next steps in the patient’s
providers3 care to the patient and family and use teach back.
Involving the patient and family in discharge planning can Listen to and honor the patient’s and family’s goals,
improve patient outcomes, reduce unplanned preferences, observations, and concerns.
readmissions, and increase patient satisfaction.6,7 This process will include at least one meeting to discuss
More and more, hospitals are focusing on transitions in concerns and questions with the patient, family of their
care as a way to improve hospital quality and safety. To choice, and named nurse or doctor.
improve quality and reduce preventable readmissions,
Midhega Primary Hospital will use the Agency for What does this mean for clinicians?
Healthcare Research and Quality’s Care Transitions from We expect all clinicians to:
Hospital to Home: IDEAL Discharge Planning tools to  Incorporate the IDEAL discharge elements in
engage patients and families in preparing for discharge to their work
home.  Make themselves available to the named nurse
who will work closely with the patient and family
 Take part in trainings on the process

Guide to Patient and Family Engagement :: 1

How do you implement
IDEAL Discharge Planning? Educate the patient and family in plain language
about the patient’s condition, the discharge process,
Each part of IDEAL Discharge Planning has and next steps at every opportunity throughout the
multiple components: hospital stay.
Getting all the information on the day of discharge can be
Include the patient and family as full partners in the overwhelming. Discharge planning should be an ongoing
discharge planning process. process throughout the stay, not a one-time event. You
 Always include the patient and family in team can:
meetings about discharge. Remember that  Elicit patient and family goals at admission and
discharge is not a one-time event but a process note progress toward those goals each day
that takes place throughout the hospital stay.
 Involve the patient and family in bedside shift
 Identify which family or friends will provide care report or bedside rounds
at home and include them in conversations.
 Share a written list of medicines every morning
Discuss with the patient and family five key areas to  Go over medicines at each administration: What
prevent problems at home. it is for, how much to take, how to take it, and
1. Describe what life at home will be like. Include the side effects
home environment, support needed, what the  Encourage the patient and family to take part in
patient can or cannot eat, and activities to do or care practices to support their competence and
avoid. confidence in caregiving at home
2. Review medications. Use a reconciled medication list
to discuss the purpose of each medicine, how much Assess how well doctors and nurses explain the
to take, how to take it, and potential side effects. diagnosis, condition, and next steps in the patient’s
care to the patient and family and use teach back.
3. Highlight warning signs and problems. Identify
warning signs or potential problems. Write down the  Provide information to the patient and family in
name and contact information of someone to call if small chunks and repeat key pieces of
there is a problem. information throughout the hospital stay

4. Explain test results. Explain test results to the patient  Ask the patient and family to repeat what you
and family. If test results are not available at said back to you in their own words to be sure
discharge, let the patient and family know when that you explained things well
they should get the results and identify who they
should call if they have not gotten results by that Listen to and honor the patient and family’s goals,
date. preferences, observations, and concerns.

5. Make followup appointments. Offer to make  Invite the patient and family to use the white
followup appointments for the patient. Make sure board in their room to write questions or
that the patient and family know what followup is concerns
needed.  Ask open-ended questions to elicit questions
and concerns.
 Use Be Prepared to Go Home Checklist and
Booklet (Tools 2a and 2b) to make sure the
patient and family feel prepared to go home

Guide to Patient and Family Engagement :: 2

 Schedule at least one meeting specific to
discharge planning with the patient and family
caregivers

Guide to Patient and Family Engagement :: 3

IDEAL Discharge Planning Process
The elements of the IDEAL Discharge Planning process are incorporated into our current discharge. The information
below describes key elements of the IDEAL discharge from admission to discharge to home. Note that this process
includes at least one meeting between the patient, family, and discharge planner to help the patient and family feel
prepared to go home.

Initial nursing assessment Daily

 Identify the caregiver who will be at home  Educate the patient and family about the
along with potential back-ups. These are the patient’s condition at every opportunity, such
individuals who need to understand instructions as nurse bedside shift report, rounds, vital status
for care at home. Do not assume that family in check, nurse calls, and other opportunities that
the hospital will be caregivers at home. present themselves. Use teach back.
Who: All clinical staff
 Let the patient and family know that they can
use the white board in the room to write  Explain medicines to the patient and family
questions or concerns. (for example, print out a list every morning)
and at any time medicine is administered.
 Elicit the patient and family’s goals for when Explain what each medicine is for, describe
and how they leave the hospital, as
potential side effects, and make sure the patient
appropriate. With input from their doctor, work
knows about any changes in the medicines they
with the patient and family to set realistic goals
are taking. Use teach back.
for their hospital stay.
Who: All clinical staff
 Inform the patient and family about steps in  Discuss the patient, family, and clinician goals
progress toward discharge. For common
and progress toward discharge. Once goals are
procedures, create a patient handout, white
set at admission, revisit these goals to make
board, or poster that identifies the road map to
sure the patient and family understand how they
get home. This road map may include things like
are progressing toward discharge.
“I can feed myself” or “I can walk 20 steps.”
Who: All clinical staff

 Involve the patient and family in care practices

to improve confidence in caretaking after
discharge. Examples of care practices could
include changing the wound dressing, helping
the patient with feeding or going to the
bathroom, or assisting with rehabilitation
exercises.
Who: All clinical staff

Guide to Patient and Family Engagement :: 4

Prior to discharge planning meeting
When: 1 to 2 days before discharge planning meeting. For short stays, this meeting may occur at admission.

 Give the patient and family Tools 2a and 2b: Be  Schedule discharge planning meeting with the
Prepared to Go Home Checklist and Booklet. patient, family, and hospital staff.
Who: Hospital to identify staff person to distribute, Who: Hospital to identify staff person to distribute,
for example a nurse, patient advocate, or discharge for example a nurse, patient advocate, or discharge
planner. planner.

Discharge planning meeting Day of discharge

When: 1 to 2 days before discharge, earlier for more  Review a reconciled medication list with the
extended stays in the hospital patient and family. Go over the list of current
 Use the Tools 2a and 2b: Be Prepared to Go medicines. Use teach back (ask them to repeat
Home Checklist and Booklet as a starting what the medicine is, when to take it, and
point to discuss questions, needs, and how to take it). Make sure that patients have an
concerns going home. easy-to-read, printed medication list to take
home.
 If the patient or family did not read or fill out Who: Hospital to identify staff person to review
the checklist, review it verbally. Make sure to the medication list with patient and family.
ask if they have questions or concerns other Because this involves medications, we assume it
than those listed. You can start the dialogue would be a clinician — nurse, doctor, or
by asking, “What will being back home look pharmacist.
like for you?”
 Repeat the patient’s concerns in your own
 Give the patient and family the patient’s
followup appointment times and include the
words to make sure you understand.
provider name, time, and location of
 use teach back to check if the patient appointments in writing.
understands the information given. Who: Staff who scheduled appointment.
 if another clinician is needed to address
concerns (e.g., pharmacist, doctor, or nurse),
 Give the patient and family the name,
position, and phone number of the person to
arrange for this conversation.
contact if there is a problem after discharge.
Who: Hospital to identify staff to be involved in Make sure the contact person is aware of the
meeting, for example the nurse, doctor, patient patient’s condition and situation (e.g., if the
advocate, discharge planner, or a combination. primary care physician is the contact person,
Patient identifies if family or friends need to be make sure the primary care physician has a copy
involved. of the discharge summary on the day of
 Offer to make followup appointments. Ask if discharge).
the patient has a preferred day or time and if Who: Hospital to identify staff person to write
the patient can get to the appointment. contact information, for example a nurse, patient
Who: Hospital to identify staff person to do, such advocate, or discharge planner.
as a patient advocate or discharge planner.

Guide to Patient and Family Engagement :: 5

IDEAL Discharge Planning Checklist
Fill in, initial, and date next to each task as completed.
Patient Name:

Prior to Discharge During Discharge

Initial Nursing Assessment Day of Discharge
Planning Meeting Planning Meeting

Identified the caregiver Distributed checklist and Discussed patient Medication

at home and backups booklet to patient and questions
Reconciled medication list
family with explanation
Told patient and family Discussed family Reviewed medication list with patient
about Scheduled discharge questions and family and used teach back
planning meeting
Appointments and contact information
Elicited patient and Reviewed discharge
family goals for hospital Scheduled for instructions as needed Scheduled followup appointments:
stay
1) With
/ / at Used Teach Back
on
Informed patient and
family about steps to [time] Offered to schedule / / at [time]
discharge followup appointments
2) With
with providers.
on
Preferred dates / times
for: / / at [time]

Arranged any home care needed

PCP:

Wrote down and gave appointments to the

Other: patient and family

Wrote down and gave contact information

for followup person after discharge

Guide to Patient and Family Engagement :: 6

IDEAL Discharge Planning Daily Checklist
Fill in, initial, and date next to each task as completed.
Patient Name:

Day 1 Day 2 Day 3 Day 4

Educated patient and family Educated patient and family Educated patient and family Educated patient and family
about condition and used about condition and used about condition and used about condition and used
teach back teach back teach back teach back

Discussed progress toward Discussed progress toward Discussed progress toward Discussed progress toward
patient, family, and clinician patient, family, and clinician patient, family, and clinician patient, family, and clinician
goals goals goals goals

Explained medications to Explained medications to Explained medications to Explained medications to

patient and family patient and family patient and family patient and family
Morning Morning Morning Morning
Noon Noon Noon Noon
Evening Evening Evening Evening
Bedtime Bedtime Bedtime Bedtime
Other Other Other Other

Involved patient and family in Involved patient and family in Involved patient and family in Involved patient and family in
care practices, such as: care practices, such as: care practices, such as: care practices, such as:

Notes

Guide to Patient and Family Engagement :: 7

References

Guide to Patient and Family Engagement :: 8

1
.Forster AJ, Murff HJ, Peterson JF, et al. The
incidence and severity of adverse events
affecting patients after discharge from the
hospital. Ann Intern Med 2003;138(3):161–7.
2
. Jencks SF, Williams MV, Coleman EA.
Rehospitalizations among patients in the
Medicare fee-for-service program. N Engl J
Med 2009;360(14):1418–28.
3
.Kripalani S, Jackson AT, Schnipper JL, et al.
Promoting effective transitions of care at
hospital discharge: a review of key issues for
hospitalists.
J Hosp Med 2007;2(5):314–23.
4
.Anthony MK, Hudson-Barr D. A patient-
centered model of care for hospital discharge.
Clin Nurs Res 2004;13(2):117–36.
5
.Popejoy LL, Moylan K, Galambos C. A review
of discharge planning research of older adults
1990–2008. West J Nurs Res 2009;31(7):923–47.
6
.Bauer M, Fitzgerald L, Haesler E, et al. Hospital
discharge planning for frail older people and
their family. Are we delivering best practice? A
review of the evidence. J Clin Nurs
2009;18(18):2539–46.
7
.Shepperd S, McClaran J, Phillips CO, et al.
Discharge planning from hospital to home.
Cochrane Database Syst Rev. 2010;20;
(1):CD000313.