ANMCO Position Paper: hospital discharge planning: recommendations and standards

Abstract

The hospital discharge is often poorly standardized and affected by discontinuity and fragmentation of care, putting patients at high risk of both post-discharge adverse events and early readmission. The present ANMCO document reviews the modifiable components of the hospital discharge process related to adverse events or re-hospitalizations and suggests the optimal methods for redesigning the whole discharge process. The key principles for proper hospital discharge or transfer of care acknowledge that the hospital discharge:• is not an isolated event, but a process that has to be planned as soon as possible after the admission, ensuring that the patient and the caregiver understand and contribute to the planned decisions, as equal partners;• is facilitated by a comprehensive systemic approach that begins with a multidimensional evaluation process;• must be organized by an operator who is responsible for the coordination of all phases of the hospital patient journey, involving afterward the general practitioner and transferring to them the information and responsibility at discharge;• is the result of an integrated multidisciplinary team approach;• appropriately uses the transitional and intermediate care services;• is carried out in an organized system of care and continuum of services; and• programs the passage of information to after-discharge services.

Atividades das enfermeiras de ligação na alta hospitalar: uma estratégia para a continuidade do cuidado

“…Planning for hospital discharge is a process that needs to be started shortly after the patient is hospitalized, specifically within the first 24 hours. In this way, it is possible to identify the obstacles to discharge and to implement corrective actions 17 . The discharge planning, being a process, is characterized by different moments: in the admission, data can be collected related to the cognitive state, support systems and domestic environment; risk factors, such as the need for learning, can be evaluated near the discharge of the patient 16 .…”

“…The discharge planning does not only help the different health professionals to coordinate their services in a complementary way, but also to delineate a path of care expected for each patient, which promotes a sense of security to them and a basis for the taking shared decision 18 . In general, all inpatients require a discharge plan, which may be more or less specific 17 .…”

The development and testing of the Predictor of Appropriate Discharge Destination among patients undergoing elective total knee or hip joint arthroplasty

“…Using this predictor tool clinically provides an early intervention for identifying discharge placement. Mennuni et al 27 recommended that the discharge planning process needs to occur as soon as possible after admission. The PADD tool is completed on postoperative day zero with shared input from a multidisciplinary team; the tool enhances the efficiency and accuracy of placement selection while removing the biased discharge preferences of any one discipline.…”

Consensus Recommendations for Optimizing Electronic Health Records for Nutrition Care

“…Discharge planning is an interdisciplinary approach to provide continuity of care. It is a process that begins at admission when the provider determines anticipated post‐hospital services and planning that includes the patient and family, development of a structured discharge plan tailored to meet the individual's needs, and discharge coordination rounds with interdisciplinary participants to ensure comp`letion of discharge teaching . Inclusion of resolved and unresolved nutrition diagnoses, especially malnutrition, in the hospital discharge summary provides valuable information to the primary care, referring, or next‐setting physician for ongoing treatment.…”