What Is Skilled Discharge Planning?

Skilled discharge planning involves working with professionals in several disciplines to create a plan of care for an individual who is leaving the hospital. The goal of skilled discharge planning is to ensure continuity of care and minimize the likelihood of future hospitalizations for the same condition.

Medical Disciplines

• Medical disciplines involved in discharge planning include doctors, nurses, medical social workers, dietitians, pharmacists, physical therapists, occupational therapists and speech therapists.

Time Frame

• Good discharge planning begins on the day of admission to the hospital, when factors such as current living arrangements and the ability of the present environment to meet medical needs are assessed by nurses and social workers.

Identification

• Hospital patients who benefit the most from skilled discharge planning include elderly patients, patients with chronic health problems, such as heart disease or diabetes, and patients whose living arrangements do not meet their health care needs, for instance because they are homeless or because there is no caregiver available.

Benefits

• Skilled discharge planning saves insurance companies, state medical assistance programs and Medicare money by reducing the likelihood of future costly hospitalizations. Discharge planning is also good for patients because it provides them with an individualized blueprint to follow to manage their health care post hospital discharge.

Misconceptions

• Not every hospitalized patient goes home after discharge planning. Depending on his or her needs, the patient may be discharged to a rehabilitation facility, a skilled nursing facility, an inpatient hospice or the home of a friend or family member who can act as a caregiver.

Other Services

• If the patient does go home, discharge planners can often arrange for a wide range of community services including home health care, home hospice, home-delivered meals, private duty care (care in the home paid for by the patient), transportation to future medical appointments and a personal medical alarm that the patient can use to summon help in the event of a fall or other emergency.