1. Perform an Enhanced Assessment of Post-Hospital Needs Before beginning improvement work, most teams believe that they are already performing enhanced assessments on admission. However, after completing the Diagnostic Review, teams gain new insights into what they are missing. Initial assessment should be completed upon admission, but ongoing assessment of home-going needs should occur throughout hospitalization. Early and ongoing assessment of a patient’s individualized care needs after a hospital discharge contributes to an individualized patient and family plan of care. Completing a comprehensive admission assessment requires additional time; roles and responsibilities need to be designated and standard work processes need to be developed. Typical failures in the assessment of discharge needs include the following: Excluding the patient and family caregivers in assessing needs, identifying resources, and planning for discharge, leading to poor understanding of the patient’s capacity to function in the home environment; Lack of probing around unrealistic patient and family optimism to manage at home; Lack of understanding of the patient’s functional ability, physical and cognitive health status, and social and financial concerns, which results in transfer to a care setting that does not meet the patient’s needs; Not addressing the whole patient (e.g., focusing on one condition, missing underlying depression, social needs, etc.);
Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society. May 2004;52(5):675-684. Project BOOST: Better Outcomes for Older Adults Through Safe Transitions – Tool for Identification of High-Risk Patients. Available at (search risk assessment tool). van Walraven C, Dhalla IA, Bell C, Etchells E, Stiell IG, Zarnke K, Austin PC, Forster AJ. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. Canadian Medical Association Journal. 2010; DOI: 10.1503/cmaj.091117. 1D. Create a customized discharge plan based on the assessment. A customized and structured discharge plan based on patient needs “reduces readmission rates for older people admitted to the hospital with a medical condition.” On the day of admission, initiate a customized plan of care based on the level of care indicated by the standardized admission assessment. In its 2003 report, “Priority Areas for National Action,” the Institute of Medicine (IOM) recommended that providers communicate and reinforce patients’ active and central role in managing their illness., The person designated to be accountable for the effective discharge of the patient (e.g., the patient’s primary nurse, a case manager, a discharge planner, a discharge coach, or a hospitalist) should initiate the patient’s plan of care based on the enhanced assessment. A customized discharge planning process includes the elements listed below. Assess and predict discharge basic needs and incorporate them into the patient’s discharge plan. Communicate with agencies early if referrals for home health care, skilled nursing, an advanced practice nurse, or a transitions coach are under consideration., Discuss preparations for discharge in daily and multidisciplinary rounds. Re-evaluate the estimated discharge date daily and adjust the plan. Standardize the discussion of preparation for rounds or bedside report. Daily goals should include progress toward going home. Questions to address include: Where will the patient likely go after discharge?