APP for Discharge Planning in KAAH

Issue Date: 21/12/1996

Revision Date: 17/05/2015
Code #: APP/DP/027
Page 1 of 12

1.0 TITLE: DISCHARGE PLANNING IN KAAH

2.0 POLICY:

Discharge Planning process shall be implemented in KAAH in the care of all patients
starting at the time of admission till discharge from the Hospital.

3.0 PURPOSE:

3.1 To define the responsibilities of all staff who participate in discharge planning
process and provide guidelines in its implementation.

4.0 OBJECTIVES:

4.1 When the patient will be discharged from service.

4.2 What goals will be met before discharge?

4.3 Specific instructions and what to do for problems.

4.4 Identify the participants in the patient’s care.

4.5 Preventive measures to prevent further problems.

4.6 Instructions for care of equipment (as applicable).

4.7 How and when to follow up with the physician.

5.0 DEFINITIONS:

5.1 Discharge Planning - is the process of preparing the patient / family for an
effective and efficient transfer out of the hospital to his / her home directly or
indirectly through another healthcare institution.

5.1.1 A Discharge Plan begins at the start of care and is developed by a

combined effort of the healthcare providers, physician, patient, and family
and others.

KAAH APP-DP-027
APP for Discharge Planning in KAAH
Issue Date: 21/12/1996
Revision Date: 17/05/2015
Code #: APP/DP/027
Page 2 of 12

5.1.2 In our environment, discharge planning begins at the time of admission.

The plan for discharge from service should be developed with input from
the physician, attending nurse, family, social worker, other ancillary staff
and other health care workers.

5.2 Discharge Planning Checklist – a form used as checklist to make the discharge
process more efficient, used in selected cases (anticipating difficult discharge),
according to patient’s needs and the judgment of the treating physician.

5.3 Family Caregivers - person who helps someone who is ill, disabled or elderly.
Keeps names phone of care givers doctors, nurses and social worker.

5.4 Ancillary Staff – social worker, dietitian, pharmacist and physical therapist.

6.0 RESPONSIBILITIES:

6.1 Discharge Planning, in terms of the acute facility, should be the responsibility of a
multidisciplinary team, coordinated by one member.

6.2 Continued involvement of doctors, nurses, ancillary services such as social

worker, dietitian, pharmacy, and physical / occupational therapy.

6.3 Traditionally, the discharge planning function is performed by the discharge

planners or social workers.

6.4 These staff members discuss the patient’s discharge needs and disposition with
the attending physician, nursing, ancillary therapy staff, the patient, and the
family to determine the appropriate community resources required by the patient
at discharge.

6.5 Responsible for the development of comprehensive plans that minimize hospital
stay.

6.6 Ensuring that clients are discharged to safe and appropriate environment.

6.7 Responsibilities of discharge team members will include attendance at clinical

rounds to identify and assess clients who require discharge planning.

6.8 Ensures optimal healthcare support for client vis-à-vis the appropriate use of the
hospital resources.
KAAH APP-DP-027
APP for Discharge Planning in KAAH
Issue Date: 21/12/1996
Revision Date: 17/05/2015
Code #: APP/DP/027
Page 3 of 12

6.9 Providing education to clients and/or the families re-discharge plans.

6.10 Education of Discharge Planning Team.

6.10.1 The patient and/or his /her family are given the following necessary
education and information by their treating physician:

6.10.1.1 The nature of their illness.

6.10.1.2 Complications that might happen.

6.10.1.3 Any surgical procedure needed and its benefits.

6.10.1.4 The potential complications or risks involved with the surgical

procedure.

6.10.1.5 The pre-operative preparations needed.

6.10.1.6 The necessary medications that are needed to be given pre-

operatively and post-operatively and their side effects.

6.10.1.7 The medications used to treat an illness, the frequency of taking

the medication, the side effects, and precautions.

6.10.1.8 Postoperative care, i.e., breathing exercises, diet and wound

care.

6.10.1.9 X-ray procedures their benefits and the potential risks involved.

6.10.1.10 Any restrictions of the diet and the reasons why restrictions are
necessary.

6.10.1.11 Proper use of the medical equipment, e.g. oxygen concentrator,

colostomy bag.

6.11 Nursing provides the following patient education:

6.11.1 Giving the patient appropriate information about their illness and the
required nursing care.

KAAH APP-DP-027
APP for Discharge Planning in KAAH
Issue Date: 21/12/1996
Revision Date: 17/05/2015
Code #: APP/DP/027
Page 4 of 12

6.11.2 Providing diet restrictions, and proper use of medications, e.g. inhalers for
asthmatics.

6.11.3 Teaching the patient on infection control guidelines, especially hand

washing and using the bathroom.

6.11.4 Explaining, demonstrating treatments, and providing pamphlets or

diagrams if available.

6.11.5 Explaining and teaching the appropriate use of the medical equipment or
appliances (e.g. colostomy bag) and ask patient to return demonstration.

6.11.6 Ensuring that patients have his / her follow-up clinic appointment.

6.11.7 Explaining the conditions in which the patient needs to seek medical
assistance by telephone and / or seek medical assistance by reporting to
the Emergency Department.

6.12 The Social Worker Assists in the Discharge Planning Process by:

6.12.1 Finding any social factor that might delay the discharge of patients.

6.12.2 Making necessary arrangements to facilitate timely discharge.

6.12.3 The social worker facilitates the continuity of care to the patient and
expedites it by responding to the needs of the patient.

6.12.4 Educates the patient on aid agencies.

6.12.5 Helps the patient obtain assistance for buying appliances, equipment,
drug.

6.12.6 Evaluate the patient’s emotional status.

6.12.7 Assist patient to overcome his / her disability.

6.12.8 Assessing the social needs of the patient so they can help the physicians to
develop a plan of care for the patient.

KAAH APP-DP-027
APP for Discharge Planning in KAAH
Issue Date: 21/12/1996
Revision Date: 17/05/2015
Code #: APP/DP/027
Page 5 of 12

6.12.9 Assessing the patient’s home situation and the patient’s non-compliance to
treatment.

6.12.10 Assessing the patient’s emotional and psychological factors that could
impact the patient’s self care ability.

6.13 The Dietitian Participates in the Discharge Planning Process by:

6.13.1 Providing patient and/or family education on therapeutic diets.

6.13.2 Documenting the patient’s response to education in the patient’s medical

record:

6.13.2.1 Provide and explain to the patient and family used to treat
his/her illness. The frequency of taking the therapeutic diets and
precautions.

6.13.2.2 Provide and explain to patient and family necessary

therapeutic diets that are needed to be given pre-operatively and
post-operatively.

6.13.2.3 Prepare the therapeutic diets list necessary for the patient to take
home upon discharge from the hospital and explain any
restrictions of the diet and the reasons why restrictions are
necessary.

6.14 Responsibilities of Pharmacy:

6.14.1 Provide and explain to the patient and family used to treat his / her illness.
The frequency of taking the medication side effects and precautions.

6.14.2 Provide and explain to patient and family necessary medications that are
needed to be given pre operatively and post operatively and their side
effects.

6.14.3 Prepare the medications necessary for the patient to take home upon
discharge from the hospital and explain how often the medications should
be taken, its side effects / or complications.

KAAH APP-DP-027
APP for Discharge Planning in KAAH
Issue Date: 21/12/1996
Revision Date: 17/05/2015
Code #: APP/DP/027
Page 6 of 12

6.15 Responsibilities of Doctors:

The patient and/or his family are given the following necessary education and
information by their Treating Physician:

6.15.1 The nature of their illness.

6.15.2 Complications that might happen.

6.15.3 Any surgical procedure needed and its benefits.

6.15.4 The potential complications or risks involved with the surgical procedure.

6.15.5 The pre-operative preparations needed.

6.15.6 The necessary medications that are needed to be given pre-operatively and
post-operatively and their side effects.

6.15.7 The medications used to treat an illness, the frequency of taking the
medication, the side effects, and precautions.

6.15.8 Postoperative care, i.e., breathing exercises, diet and wound care.

6.15.9 X-ray procedures, their benefits and the potential risks involved.

6.15.10Any restrictions of the diet and the reasons why restrictions are necessary.

6.15.11Proper use of the medical equipment, e.g. oxygen concentrator, colostomy

bag.

6.16 Responsibilities of Home Care:

6.16.1 Devise, coordinate and implement a patient discharge planning from

Home Health Care.

6.16.2 Teach implement and evaluate care and monitor patient care outcomes.

6.16.3 Comprehensive Home Health Care Assessment includes Physician,

Nurses, Social Worker, Physiotherapist, Respiratory Therapist and
Dietitian.

KAAH APP-DP-027
APP for Discharge Planning in KAAH
Issue Date: 21/12/1996
Revision Date: 17/05/2015
Code #: APP/DP/027
Page 7 of 12

6.16.4 Home Health Care Physician/Nurse begins Discharge Planning on

admission when goals are mutually established.

6.16.5 Home Health Care Team shall ensure the patient is discharged to home
care with all required medicines and other necessary facilities such as
equipment, etc.

6.16.6 Home Health Care Team makes initial medical, nursing, social assessment
of the patient and family.

6.16.7 Makes arrangements with the family for frequency of visits and
implements the required treatment for improvement.

6.16.8 Reassessment of care plan and outcomes of care with appropriate

documentation is carried out.

6.16.9 Terminally ill patient shall receive appropriate pastoral care.

6.17 Discharge Planner:

6.17.1 Responsible for the development of comprehensive plans that minimize

hospital stay.

6.17.2 Ensuring that clients are discharged to safe and appropriate environment.

6.17.3 Responsibilities will include attendance at clinical rounds to identify and

assess clients who require discharge planning.

6.17.4 Ensures optimal healthcare support for client vis-à-vis the appropriate use
of the hospital resources.

6.17.5 Providing education to clients and/or the families re-discharge plans.

7.0 PROCEDURES:

7.1 Patients and their families need to know the expectations of the healthcare team in
term of anticipated length of stay, the patient’s expected condition at discharge
and the potential need for aftercare services.

KAAH APP-DP-027
APP for Discharge Planning in KAAH
Issue Date: 21/12/1996
Revision Date: 17/05/2015
Code #: APP/DP/027
Page 8 of 12

7.2 It is most important that the patient and family are aware of the need to make
arrangements for continued care in a timely fashion and are assisted with
accessing appropriate community resources and institutions.

7.3 It is most important that the physician and nursing and ancillary staffs maintain a
current knowledge base with respect to community resources, particularly new
programs which periodically become available. An awareness of this information.

7.4 The Multidisciplinary Discharge Planning Checklist shall be by filled for selected
cases by each discipline according to the patients needs upon admission.

7.5 In the event a patient’s competency is questioned, there must be a carefully

outlined procedure to legally ascertain competency.

7.6 The procedure for the investigation of living will status, power of attorney for
healthcare decisions, and guardianship issues must be clearly documented in the
organization’s policies.

7.7 There should be policies and procedures governing the responsibility and
authority of managing potentially inappropriate discharges.

7.8 Implement clearly delineated guidelines with respect to proper assessment,

reporting, and follow-up for any suspected patient abuse.

7.9 The hospital has informal or formal arrangements with other institutions to accept
patients for transfer when the care required is beyond the scope of service
provided by the hospital and includes:

7.9.1 Communication of arrangements for care with other institution to all

department heads.

7.10 What are the environmental limitations of the individual’s residence support the
plan?

7.10.1 For example:

7.10.1.1 Is there 220 wiring to support any special equipment needs?

7.10.1.2 Is there clean adequate water?

KAAH APP-DP-027
APP for Discharge Planning in KAAH
Issue Date: 21/12/1996
Revision Date: 17/05/2015
Code #: APP/DP/027
Page 9 of 12

7.10.1.3 Is the home clean and free from germs?

7.10.1.4 Is home clean debris free sufficient to prevent accident hazards

in elderly and individuals with disabilities (for ex. A throw rug
may not pose an accident risk for most people, but may someone
with an unsteady gait?)

7.10.1.5 Does the home provide adequate access for an individual with
disabilities or does the home require modifications?

7.10.2 It should be very clear on any limitations are and whether or not the
patient will need special care, assistance, or equipment following surgery.
The following items should be:

7.10.2.1 Are there any special dietary restrictions to be followed?

7.10.2.2 How soon before the patient can resume driving and other
routine activities.

7.10.2.3 Who will help the patient once you get home until normal
activities can be resumed?

7.10.2.4 What are special instructions regarding incisional care?

7.10.2.5 How long should the patient expect the pain to last?

7.10.2.6 When can the patient resume exercise and other rigorous
activities?

7.10.2.7 How soon before the patient can return to work?

7.10.3 In addition, the healthcare team is aware of the patient’s expected needs
for hospital services as well as aftercare requirements. Example, a patient
undergoing a total hip replacement may require short-term rehabilitation.

7.10.4 Arrangements for patient transport includes an estimation of the length of

time required for transport, and an assessment of patient needs during
transfer and includes:

KAAH APP-DP-027
APP for Discharge Planning in KAAH
Issue Date: 21/12/1996
Revision Date: 17/05/2015
Code #: APP/DP/027
Page 10 of 12

7.10.4.1 An assessment of the patient’s needs for Medivac-transfer.

7.10.4.2 Communication of the patient’s needs during transfer to

appropriate staff.

7.10.4.3 An attending physician determining the patient’s need for

transfer to another institution, the most suitable time for transfer,
and if the receiving institution is able to meet the patient’s needs.

7.10.5 Receiving institutions receive the necessary information to provide care to

the patient and this includes the following:

7.10.5.1 Reason for the patient’s admission.

7.10.5.2 Patient diagnosis.

7.10.5.3 Brief summary of hospitalization (therapies, consultations, non-

invasive procedures to date).

7.10.5.4 Medication list.

7.10.5.5 Condition at the time of transfer.

7.10.5.6 Reason for transfer.

7.10.5.7 Whenever possible, the patient’s X-rays are sent with the patient
to avoid further delay in treatment (E.g. trauma patients, acute
head injury).

7.10.6 Transfer are done quickly and safely especially in emergency cases (E.g.
Trauma, or Cardiac emergency) and the medical staff ensure that the
patient’s needs are met by:

7.10.6.1 Assigning a qualified physician or paramedic (as appropriate) to

accompany the patient and handle any emergency that might
happen during transfer.

7.10.6.2 Assigning a physician certified in BCLS (preferably ACLS) to

accompany all critically ill patients or intubated patients.

KAAH APP-DP-027
APP for Discharge Planning in KAAH
Issue Date: 21/12/1996
Revision Date: 17/05/2015
Code #: APP/DP/027
Page 11 of 12

7.10.6.3 Having adequate equipment and supplies on the ambulance.

8.0 FORMS/EQUIPMENT:

8.1 Plan of Care

8.2 Discharge Summary

8.3 Discharge Planning Checklist

9.0 REFERENCE(S):

9.1 Medical Consultant Network © Inc

9.2 Joint Commission International Accreditation Standards for Hospitals, 5th Edition
1 April 2014

10.0 REVISION:

10.1 This policy shall be revised every 2 years.

KAAH APP-DP-027
APP for Discharge Planning in KAAH
Issue Date: 21/12/1996
Revision Date: 17/05/2015
Code #: APP/DP/027
Page 12 of 12

11.0 APPROVALS:

11.1 Prepared by: __________________________________ _____________

Dr. Aliah Abdulghaffar Date
Quality & Patient Safety Consultant

11.2 Reviewed by: __________________________________ _____________

Dr. Eiman Hawary Date
Director of Quality Improvement

11.3 Approved by: __________________________________ _____________

Ms. Fawziah Bakheet Al Mowalad Date
Director of Nursing Services

11.4 Approved by: __________________________________ _____________

Dr. Reda Matbuli Date
Assistant Supervisor General for Medical Affairs

11.5 Approved by: __________________________________ _____________

Dr. Faisal Bin Mahmoud Tallab Date
Supervisor General

KAAH APP-DP-027