What is “Discharge Planning”?

The term discharge planning is probably quite familiar for anyone who has had a family member stay in the hospital, or who has had the experience of being an inpatient. However, for those of you who don’t know, you may be wondering, what is it, and why it is so important?

A very basic explanation of discharge planning is, that it’s a plan for leaving the hospital. In most hospitals, the goal is to make the discharge as safe and patient-centered as possible. Hospitals do not want to have the patient returning due to the plan not working out, nor would a patient want to re-experience the stress of having to return for further inpatient care.

Discharge planning is a complex series of activities that, when done correctly, begins at or before admission. The earlier a patient starts to think about their care post-discharge, the better the plan.

At the University of Washington Medical Center (UWMC), many people are involved in discharge planning: physicians, nurses, therapists, pharmacists, nutritionists, and other professionals. The social worker coordinates any discharges necessitating a move to another level of care, such as a nursing home, or one that requires home health, hospice, or in-home services. UWMC utilizes Masters prepared social workers, because of the many clinical, emotional, and organizational details involved in discharge planning.

Take the case of Ms. W., a 79 year-old woman needing knee surgery. As soon as the surgery is scheduled at UWMC, Tracy, our orthopedic social worker, receives the information and calls Ms. W. Tracy begins by asking about Ms. W’s living situation, so together, they can determine Ms. W’s needs after surgery. Practical questions are asked as well, such as whether Ms. W. has stairs to climb, the distance from the driveway to the house, and how close the bathroom is to the bedroom. Tracy will also ask Ms. W. if she has anyone available to care for her when she comes home from the hospital, and try to assess if in-home help will be needed. Most importantly, Tracy will want to discuss Ms. W’s expectations about the surgery, and what concerns or questions she might have about managing a safe recovery. After Ms. W. and Tracy agree on a tentative plan, Tracy will then set up any needed services. When Ms. W. comes to UWMC for her surgery, the plans will be confirmed, and any necessary changes can be made as needed. This process ensures that Ms. W. is fully prepared not only for the surgery, but for the necessary recovery period.

We understand that not every hospital admission can be planned in advance, but our goal at UWMC is to begin preparing our patients for a safe discharge as soon as possible .We don’t want there to be any surprises when the time comes to leave the hospital. In the event that an unexpected situation does arise, and the patient needs assistance, the social worker is immediately contacted. They meet with the patient and his or her family to offer assistance, and to inquire about any immediate or longer-term needs.

In Mr. Ds case, he was a robust 65 year-old who collapsed on the tennis court from a major heart attack. An unplanned admission can be traumatic, so besides being ready to help with discharge planning, Karen, our Cardiac Surgery social worker, would help Mr. D. with the emotional toll that can come with an unexpected change in health. It would not be uncommon for a patient such as Mr. D. to feel overwhelmed, afraid, and saddened by his loss of health. Karen would listen, and provide support to Mr. D. and his family. She would help him adjust to any changes that may have to occur in the present, and for the long-term.

If a short-term stay in a rehabilitation facility were determined to be helpful for Mr. D., Karen would talk with him about his choices, and work to arrange a placement. If Mr. D’s wife wants to manage the care in-home, Karen could supplement the care with home care services and/or home health. Karen might also provide Mr. D. with information on support services for cardiac patients, so that Mr. D. could better manage the shock of a sudden health crisis. At UWMC, we feel that it makes common sense to anticipate any barriers to a safe discharge, and ongoing adherence to treatment. Listening, collaborating, and being responsive to what the patients say is the best recipe for recovery. We can help achieve this by creating a successful discharge plan, which could only lead to the best positive health outcome.