DISCHARGE PLANNING

& REFERRALS
MELANIE MORANO, JD, MSN, RN
 CARE STUDY
Mr. Homer Needin is being discharged from the hospital today. He has
shattered his left ankle falling off of a second-story porch and is
scheduled to return for surgery on the ankle in two weeks. He lives
alone in an 100-year-old home that needs considerable repair, has a
leaking roof, no water and no heat. He has no health insurance, no job,
no transportation, no assistance from family, very little assistance from
friends. His income is inconsistent and was dependent on occasional
construction work, which he cannot do for at least the next six months.
What factors would you consider in preparing him for discharge?
What actions would you take in assisting him with discharge?
What Teaching is Important During
Discharge Planning?
1. Medications
2. Procedures
3. Nutrition
4. Follow-up plans
5. Plan for highest level of wellness
6. Miscellaneous
7. After surgery
8. Caregiver
Elcaminohospital.org executivenursingservices.com projecthop.org
 CARE STUDY
Discharge is planned for Mr. Jones (age 82) tomorrow morning. During
this hospitalization he experienced new onset angina, he was
prescribed metoprolol for his blood pressure, he has lab scheduled for
once monthly for the next 2 months, and he has a fractured arm from
falling out of bed with wound dressings BID. He lives with his elderly
wife who has mild dementia.
What factors would be important to consider in planning for his
discharge?
How Should Discharge Planning be
Documented?
1. Plan for discharge
2. Preparation for Discharge
3. Preparation of patient for discharge
4. Day of discharge
5. Patient’s status on discharge
6. Teaching for discharge
7. Copy of any materials given
Napequity.org
What are Cultural Aspects of Discharge
Planning?
1. For patient- Limitations on who can care for patient?
2. For caregiver-Limitations on who they can care for?
3. In general- Religious services to attend? Language barriers?
4. Dietary considerations

Mh4h.org

Health.qld.gov.au

Satyamthetruth.com
QUESTION
How might the following cultural characteristics affect discharge planning?
A. Present-oriented versus past-oriented?
B. Needs of the family supersede the needs of the individual?
C. Health care decisions made by the family?
D. Genetic variation in sensitivity to pain medication?
E. Lack of control over environment?
F. Religion requires a vegetarian diet?
G. Speaks a different language?

Stanhope p. 82-85
What if the Patient Leaves the Hospital
Against Medical Advice (AMA)?
1. Is a reality
2. May give warning
3. Try to dissuade
4. Notify
5. Ask to sign form
6. Have form witnessed
7. Document
Pinterest.com
What is a Referral?
The process of sending or guiding the patient to another source for
assistance
Healthcare providers make referrals to community programs for post-
discharge care
Continuous coordinated care avoids duplication of effort in caring for
the patient
Examples- hospital to home health referral, school nurse to hospital,
community health nurse to Department of Health
Son.wisc.edu; retroland.com
REFERRAL OPTIONS
http://www.sitemason.com/files/g6b1jG/Catholic%20Charities%20Cent
ral%20Mississippi%20Resource%20Directory.pdf

Catholic Charities Central Mississippi Resource Directory

Ccsnn.org
What is the Referral Process?
1. Policies for referrals
2. Special forms
3. Approval by insurance carrier
4. Needs should be anticipated and referrals made as soon as possible
5. Involve the patient and family in the process

Carolinashealthcare.org
What Communication is Necessary for
Successful Referral?

1. Basic patient information (name, insurance, etc.)

2. Summary of patient’s condition and care received
3. Plan for care that agency will provide
4. Patient condition on discharge
5. Give patient/family agency contact info
6. Client must give consent for referral (exception- legal requirements)
Orchid.cancer.org.uk
What is Home Health Care?
1. A component of community based nursing
2. Nurses make visits into the home capfundinc.com

3. Nursing through home care agencies, public health agencies, visiting

nurse associations, hospitals, faith based organizations, schools,
clinics, occupational health
4. Holistic care through collaboration with multiple disciplines
5. Continued care for acutely and chronically ill patients
What are Some Examples of Services
Provided by Home Health Care Agencies?
1. Pharmacy services
2. High-tech services
3. Skilled professional/paraprofessional services
4. Custodial services
5. Durable equipment services
6. Hospice services
7. Community support services visitingnurse.org
Why is Home Health Needed?
Aging population
Mobile society
Patient’s discharged sicker
Choosing to die at home
Third party payors - reduce costs
Chronically ill patients
Changes in public funding
Family members don’t know how to use equipment
Providing care at home different from hospital

Khou.com
What is Needed for a Home Health
Referral?
1. HCP must write order for specific care (lab work, dressing change,
teaching, PT/OT, etc.)
2. Must meet criteria (primarily home-bound, have a payor source)
3. Provide information to agency (kind of surgery, meds, physical and
mental status,
4. Reason need assist –
ex. frail caregiver, no caregiver

Partnersinhomecare.org
Who is the Patient in Home Health Care?
1. The Patient
2. The Family
3. The Caregiver
4. All may be involved in doing all the
things the nurse does at the hospital

Glatfelters.com
What is done at a Home Visit?
Must have permission by client to enter
Assess patient, family, caregiver, environment,
need for additional resources
Build a relationship and establish a plan of care
Perform skills
Inform of agencies’ policies, practices, and hours
On-call information, s/s to call for help
Review main points, leave written instructions
3hc.org crmc.org
What Kind of Data is Required for an
Effective Home Plan of Care?
1. Mental status 10 The needs of the family/caregiver
2. Types of services and equipment required clipartpanda.com

3. Prognosis and rehabilitation potential

4. Functional limitations 11. Knowledge of what family/caregiver
5. Activities permitted understands about care needed
6. Nutritional requirements 12. Availability of community resources
7. Medications and treatments 13. Resources to relieve caregiver stress
8. Safety measures to protect against injury(respite services, adult day care)
9. Instructions for timely discharge 14. Support systems for difficult decisions
What are ethical considerations for the home health nurse?

The nurse is a guest

Acceptance
May have to improvise
Infection control
Confidentiality
Honor visit times
Honor patient’s rights

Npr.org america.aljazeera.com blog.icrc.org

What is the Role of Documentation in
Home Health Care?
Mandatory by regulatory and federal agencies
Homebound status and need for professional skilled
care, medical diagnosis, plan of care, functional
limitations, goals and planned interventions,
expected outcomes
Inadequate documentation may result in
nonpayment for the visit and care services
Use OASIS for documentation
Webcms.pima.gov healthcareprovidersolutions.com
What is Hospice Care?
1. Support services for the terminally ill
2. Nurses provide education, nursing care, SW services, MD services,
counseling, aide and homemaker services, supplies, meds, PT/OT,
ST, bereavement services
3. Patients are eligible for hospice if they are determined to be within
the final 6 months of life
4. Hospice care in rural setting provides especially valuable services
where healthcare is not readily available
5. Nurse practitioners may be utilized in hospice services dslii.com
What are Occupational Health Programs?
1. Federal law (OSHA)
2. Occupational health nurses (direct care, screening, teaching, etc.)
3. Must be knowledgeable about regulations
4. May need to report some findings

Abohn.org; nasa.gov; nursingfaq.com

What is a School Health Program?
1. Provide services to students
2. School may serve as a primary care site
3. Care providers, educators, consultants, counselors
4. Collaborate with students, parents, administrators, and other health and social service
professionals
5. Perform screenings, care for minor injuries
6. Need to be knowledgeable re regulations affecting school children
7. Health education consultants

Pinterest.com; urmc.rochester.edu
How are the Homeless Cared For?
1. Homeless population is increasing
2. Multiples causes of homelessness va.gov

3. Those lacking adequate health care funding often delay treatment and deteriorate
more quickly
4. Shelters are often overcrowded and promote contagious disease
5. The homeless have a lower life expectancy
6. Many of their health problems are related to their living situation
7. Have high rates of trauma, contagious diseases, mental illness, dental problems,
heart and lung diseases
8. Nursing care is aimed at evaluating their health needs and attempting to obtain
needed health services
What is Healthy People 2020?
Launched by the U.S. Dept. of Health and Human Services
Goals-
PH-1 - Increase use of core competencies for public
health professionals
PhI-4 - Improve education in public health areas
PHI-13 - Increase comprehensive epidemiology serviceshealthypeople.gov

PHI-14 - Improve performance of public health system

PHI-15 – Increase use of state health improvement plans
How Does the Mississippi Dept. Of Health
and Human Services Help the
Community?
1. “Seeks to empower families being served to become self-sufficient
and responsible for their future success.”
2. 7 program divisions
a. Aging and Adult Services
b. Early Childhood Care and Development
c. Family and Children’s Services
d. Family Foundation and Support
e. Field Operations
f. Youth Services lehighcounty.org
What are Some Other Community
Services Available?
1. Respite care- time away for care giver
2. Adult Day Care va.gov

3. Managed Care- to control cost while maintaining quality care

4. Personal Care Homes
5. HMO- Health Maintenance Organization- lower premiums and co-
pays
6. Third Party Payer- pay monthly premiums and insurance pays for
care
What are Nursing Diagnoses Related to
Discharge Planning/Referral?
Anxiety
Risk for Caregiver Role Strain
Readiness for Enhanced Coping
Delayed Surgical Recovery
Effective Enhanced Therapeutic Regimen Management
Risk for Infection
Impaired Home Maintenance
Caregiver Role Strain
Readiness for Enhanced Knowledge
Readiness for Enhanced Parenting
eldercareresourcesedmonton.com; livehomeblog.com
Activity Prepare a plan for discharge
Mr. Wing, age 83, is being discharged in three days. He has been in the
hospital for the past 10 days due to cardiac and respiratory problems. He is
going home on home oxygen and needs daily IV therapy and weekly lab
work. He is not expected to live to see his next birthday. He requires a low
sodium diet, becomes extremely short of breath with activity, and needs
assistance with his ADL’s. He also needs some sort of assistive device for
walking. He lives with his wife who is severely disabled due to a back
injury and a grandson who is unemployed, abuses drugs, and is a smoker.
You have reason to suspect that the grandson, his sole caregiver, has at
times slapped Mr. Wing and his wife. The rest of Mr. Wing’s family moved
to a neighboring state last year for better employment opportunities.
Activity 2 Prepare a plan for discharge
Mr. Smith, age 23, is being discharged tomorrow. He has been in the
hospital for the past 6 days after a bullet wound to his abdomen
brought him close to death. He will require twice-daily dressing
changes and a high-protein diet for wound healing. He must not return
to work for the next 4 weeks and has no other source of income. His
wife is the person who shot him in a rage because he sent a text
message to his old girlfriend. He refused to press charges, forgave her
and plans to try to make the relationship work. He plans to rely on her
salary for support until he can work again. She will be his primary
caregiver and needs instruction on how to do the dressing changes.
GOING HOME!
Fhn.org Trustpointhospital.com jarofquotes.com