Discharge Planning and Assessment Key to Avoiding Hospital Readmission

January 5, 2018 Jeanette Stern

Discharge planning and assessment for safety and mobility remain keys to reducing hospital readmission rates. Regardless if a patient is leaving the hospital, skilled nursing facility, or the ER, several factors can predict a safe convalescence at home. These are: mobility, access to food, ability to manage medications, and home health are factors which should be assessed.

People should be able to safely manage to get out of bed and a chair, and ambulate to the bathroom using their walker or other appliance. This involves being able to get up and down, and safely using the walker. For facilities that provide walkers, making sure there is a walker or other assistive device at home, or some way to obtain one, is critical. The generalized weakness that can precipitate falls in the frail elder can be made worse by acute illness, medication side effects, lack of food and drink, and other factors. If the person is falling or is unable to ambulate successfully, other planning must be done before discharge.

It is necessary to ensure that people have access to food and the ability to feed themselves. Meals on Wheels or other food delivery services can provide some access, but if people cannot make it to the kitchen, or stand long enough to cook, plans need to be made for adequate nutrition. This is especially critical regarding adequate hydration, as dehydration and the inability to get fresh drinking water can make the risk of falls significantly worse. For those with limited mobility, home health or family help must be provided to ensure adequate nutrition and hydration.

The ability to get prescription medications from a pharmacy might be challenging for people who have recently lost the ability to drive. A critical piece of discharge planning involves not just that new prescriptions are sent to the pharmacy, but that people can get them, have money to pay for them, and can manage their prescriptions and medications at home. An updated medication list is essential, as it is very easy to mix pill bottles up in the stress of coming back home ill. People should be able to describe how they keep their old medications separate from the new, and how they manage their pill boxes or other assistive devices.

If people are going home with new medical devices, such as catheters, drains, new-use oxygen, or other technology, care must be taken to teach how to walk with and manage the devices. Home health nursing should be scheduled to assess and change the devices as needed, but the risk of trip-and-fall with new tubing is high. If wound care is needed at home, any specialized supplies or medications needed should be prescribed, and the ability of the patient to access the supplies ensured.

Discharge planning staff should ensure not just that home health is scheduled to come, but what level care has been ordered, and the schedule for the first three days. If family is available, someone should consider staying with the person at least the first three days out of hospital. This can eliminate some of the problems related to access to food and drink, medications, and mobility issues.

For both the patient and the family, specific criteria should be discussed that would involve bringing the person back to the hospital, and where they should be taken. Issues such as the inability to keep water down orally, a fall with injury, a fever, a medication side effect, or a problem such as a drain or catheter being pulled out should be discussed with a plan of action, and when to return to the hospital.

Discharge planning and careful assessment of mobility, the ability to eat and drink independently, and the ability to manage medications at home are some of the factors that can make a successful transition from the hospital to home. For more information, please contact us.

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