Interdisciplinary Discharge Planning
NURSING CORE COMPETENCIES:
FOR INTERDISCIPLINARY DISCHARGE PLANNING
“The Nurse of the Future will interact effectively with patients, families,
and colleagues, fostering mutual respect and shared decision making to
enhance patient satisfaction and health outcomes” (Masters, 2014, p.78).
“The Nurse of the Future will function effectively within nursing and
interdisciplinary teams, fostering open communication, mutual respect,
shared decision making, team learning, and development” (Masters,
WHAT IS COMMUNICATION?
A process that includes 5 factors:
SENDER – encodes a message to be transmitted;
MESSAGE – the ideas, symbols, signals being transmitted;
CHANNEL/MEDIUM – the means by which a message travels; and
RECEIVER – receives and decodes the message;
FEEDBACK – Receiver provides back to Sender to signal effective
reception of intended message (Oxford University Press, 2014;
Communication Models andTheories, n.d.).
(Oxford University Press,2014).
Scenario: During Admission Intake, Nurse Hope Soeiltry would like to obtain a
medication list from PatientWill U. Listinclose for a safe medication reconciliation.
Sender (Nurse: Hope) – encodes her message with words by asking a question
Message (The Question) – what medications do you take at home? Can you tell me and
write them down on this paper to include the name, dose, and time you take them?
Channel/Medium (Verbal/Written) – both verbal and written responses
Receiver (PatientWill) – decodes the message; begins to tell Nurse Hope his medications
from home while writing them down
Feedback (Patient:Will) - asks if he should write down his over-the-counter medications
while showing Nurse Hope his medication list in progress. Nurse Hope nods in agreement
while saying,“absolutely correct!”.
Outcome of Communication: SUCCESS!
BARRIERS TO SUCCESS
Noise or Interference – ambient noise, alarms, bells, televisions, radios;
Medium chosen poorly – incompatible language, incompatible medium
i.e. hearing impaired (chose verbal transmission), visually impaired or
illiterate (chose written transmission);
Message – unclear, inappropriate, incongruent, lacks context;
Receiver – emotionally/psychologically compromised (angry, anxious,
sad, fearful, uncooperative/unreceptive); physically compromised (pain,
fatigue, altered mental status);
Feedback – Receiver did not provide feedback to ensure successful
communication occurred; Sender did not request for feedback
(Communication Models and Theories, n.d.).
STRATEGIES TO OVERCOME BARRIERS:
Sender – is clear, concise, and congruent during message transmission
Reduce or Eliminate – sources of interference with a calm, quiet, and
timely delivery environment for the communication to take place
Select Appropriate Medium – relative to the age, ethnic/cultural, and
language determined to be compatible with the receiver
Assess the Receiver – for readiness i.e.Alert, oriented, well rested, with
a reasonable mood disposition
Request Feedback – ask the receiver is they understood the message
delivered; exercise a repeat-back and verify process to ensure successful
DISCHARGE PLANNING AND EFFECTIVE
COMMUNICATION: WHAT &WHEN
“Preparation for moving a patient from one level of care to
another within or outside the current health care agency”
(Bulechek, Butcher, Dochterman, & Wagner, 2013, p.150).
“Planning for discharge begins during the initial contact with the
client by establishing the expected outcomes and anticipating
follow-up care that may be needed” (Harkreader, 2007, p.206).
DISCHARGE PLANNING AND EFFECTIVE
Poor Planning and Discharge Communication is Costly:
“Poor communication can endanger patients’ lives and waste fiscal and
human resources” (Lattimer, 2011).
“Delays, omissions, and inaccuracy of discharge information are
common at hospital discharge and put patients at risk for adverse
outcomes” (Harlan, 2010).
“It’s often poor communication, coupled with an expectation that
patients or caregivers will remember and relate critical information,
which can lead to dangerous, even life-threatening, situations” (Lattimer,
RN DISCHARGE ACTIVITIES: OVERVIEW
NURSING INTERVENTIONS CLASSIFICATION (NIC) SUMMARY
Assist patient/family/significant others to prepare for discharge;
Collaborate with interdisciplinary team/patient/family/significant others;
Coordinate with other providers for a timely discharge;
Identify patient / caregiver knowledge or skills required for discharge;
Identify patient teaching required for post-discharge care;
Communicate patient discharge plans as appropriate;
Monitor readiness for discharge;
Formulate discharge maintenance plan;
Arrange post-discharge evaluation;
and Discharge to next level of care (Bulechek et al., 2013 p.150).
CASE MANAGEMENT: OVERVIEW
Screening and Intake – identify discharge disposition / placement and destination
Assess needs – financial resources, treatment plans coordinated with physician,
patient and family for smooth discharge transitions
Service planning – initiate plan of care, identify barriers to outcomes achievement,
post-discharge service need identification, setting mutual goals with family/patient
Link patient to what they need – resource utilization, appropriate length of stay
planning, evaluation of expected outcomes progress
Implement InterdisciplinaryTreatment Plan – monitor expected outcomes, begin
arranging post-discharge arrangements, re-evaluate discharge destination if needed
Evaluate Patient Care Outcomes – based on plan of care progress towards achieving
outcomes; round with the attending physician to obtain progress feedback (Cesta,
Discharge Planning Teams (Rose & Haugen, 2010).
“S-B-A-R” (Bengasco et al., 2013).
Evidence-Based Discharge Education:
“Teach-Back” (Kornburger et al., 2013).
MULTIDISCIPLINARY INTERVENTION STUDY
Based on a study conducted in a Progressive Care Unit (PCU) in a
Problem – Current Discharge Process Concerns:
Incomplete / Inaccurate Discharge Summaries
Inconsistent Discharge Education
Communication Gaps regarding: Discharge dates, time, and disposition
Intervention – Formation of Discharge PlanningTeams
Possible Outcomes – Effective Discharge Planning:
Promotes Cost-effective Use of Inpatient Beds
Increased Patient / Staff Satisfaction (Rose & Haugen, 2010).
DISCHARGE PLANNING TEAMS:
ACTIVITIES PER DISCIPLINE
Physician & P.A.
Education on pathology and surgical reports
Writes discharge prescriptions the night before discharge
Completion of discharge summaries
Education on post-discharge care requirements night before discharge
and on the day
Coordinate follow up for outstanding discharge items to be completed
fills prescriptions at Hospital Outpatient Pharmacy
Verifies insurance information as soon as possible (Rose & Haugen,
DISCHARGE PLANNING TEAMS:
JOINT ACTIVITIES – AUDIT & SURVEY
Pre-implementation of Discharge Planning Teams:
Discharge Summaries – 60% completion rate
Prescriptions Written – 45% completed night before discharge
Nursing Staff Satisfaction – 37% contentment with discharge process
Patient Satisfaction – 93% perceived a smooth process
Post-implementation of Discharge Planning Teams:
Discharge Summaries – 91% completion rate by 2007
Prescriptions Written – 88% completed night before discharge by 2007
Nursing Staff Satisfaction – 91% contentment with discharge process by 2007
Patient Satisfaction – 100% perceived a smooth process by 2007 (Rose & Haugen,
DISCHARGE PLANNING TEAMS:
KEYSTO SUCCESSFUL IMPLEMENTATION
Communication Remains Open – Across all disciplines must be
open to facilitate acceptance of changes in processes
Multidisciplinary Involvement – input from various disciplines
facilitated the efficiency of workflow by identifying barriers related to
Continuous Improvement Process – teams must be cognizant of
the changes in health care environment: Payer systems, regulatory
agencies, and processes, ready to adapt to changing conditions (Rose &
RATIONALES FOR IMPLEMENTATION
Good Communication is characterized by:
Standardization of Content
Well coordinated between disciplines (Reilly, Marcotte, Berns, & Shea, 2013).
Errors in Communication results in:
Adverse Events with Negative Patient Outcomes
Negative Emotional Impacts for Patients & Caregivers
Increased associated Costs
Increased Length of Hospital Stay
Loss of PatientTrust
Increased Risk for Litigation (Bagnasco et al., 2013; Reilly et al., 2013).
S.B.A.R – Situation, Background,Assessment, &
Recommended as a Standardized CommunicationTool
HasWritten andVerbal components for Communication at Patient Hand-
off andTransfer (Bagnasco et at., 2013)
Proposed Benefits – S.B.A.R Implementation:
Mitigation of Risk associated with poor Communication during Patient
Hand-off and Transfer i.e. Memory Failures
Standardizes Communication Styles of various healthcare workers to create
Optimizes communication timing via Standardized reporting procedure
(Bagnasco et al., 2013).
“Teach-Back” Process – “a comprehensive, interdisciplinary, evidence-based
strategy which can empower nursing staff to verify understanding, correct
inaccurate information, and reinforce medication teaching and new home care
skills with patients and families” (Kornburger et al., 2013).
Proposed Benefits – “Teach-Back: Implementation
Provides opportunity toVerify Understanding, Correct Inaccurate Information, and
Reinforce Medication Education and Home Care Skills
Valuable, Easily Implemented and Understood, and Cost-effective Education Strategy
Engages Patients and Families in learning activities
Patient and Family-centered Education Strategy (Kornburger et al., 2013).
“Teach-Back” Goal – Effective Family / Patient Self-Management
Step 1:Teach a New Concept or Skill
Step 2: Clarify or Correct Misunderstandings
Step 3:Acknowledge any Questions Patient/Family may Have
Step 4: Continue the Process until Concept or Skill is Understood
Nurse Competencies – Understand Health Literacy Principles:
Encourage Patient/Family Questions
Use Plain Language
Limit Teaching to 3-5 Concepts
Document “Teach-Back” education in the identified form (Kornburger et al., 2013).
SUMMARY & CONCLUSION
Is a vital function to ensure Patient Safety
Failures occur mostly during points of Transfer of Care
Failures carry a significant potential for Adverse Patient Events
Is best when Standardized Communication methods are utilized
Requires an Integrated, Multidisciplinary & Team Approach
Begins at Admission, is ongoing, and is constantly re-evaluative in nature
Is Patient and Family-centered; anticipating needs constantly
Requires effective communication between patients, family, and Healthcare Team
Requires pre-emptive, evidence-based discharge Education from entire team
(Bagnasco et al., 2013; Kornburger et al., 2013; Reilly et al., 2013; Rose & Haugen,
Bagnasco,A.,Tubino, B., Piccotti, E., Rosa, F.,Aleo, G., Di Pietro, P., & Sasso, L. (2013). Identifying
and correcting communication failures among health professionals working in the
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(NIC). (6th ed.). St. Louis, MO: Mosby Elsevier.
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Case Management, 21(8), 107-110.
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Harlan, G.A., Nkoy, F. L., Srivastava, R., Lattin, G.,Wolfe, D., Mundorff, M. B., & ... Maloney, C. G.
(2010). Improving Transitions of Care at Hospital Discharge-Implications for Pediatric
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Kornburger, C., Gibson, C., Sadowski, S., Maletta, K., & Klingbeil, C. (2013). Using
“Teach-Back” to Promote a Safe Transition From Hospital to Home:An
Evidence-Based Approach to Improving the Discharge Process. Journal Of
Pediatric Nursing, 28(3), 282-291. doi:10.1016/j.pedn.2012.10.007
Lattimer, C. (2011).When It Comes to Transitions in Patient Care, Effective Communication
Can Make All the Difference. Generations, 35(1), 69-72.
Masters, K. (2014). Role Development in Professional Nursing Practice. (3rd ed.). NewYork: Jones &
Oxford University Press. (2014). Shannon and Weaver’s model. Retrieved from
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Between Hospital and Outpatient Dialysis Units at Patient Discharge:A
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