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Discharge Planning Tips for New Nurses

Discharge planning can be a challenge for any nurse, let alone a new nurse. I’ve discharged many patients since I became a nurse in 2010 and would like to give you some discharge planning tips!

Now, we’ve all heard that old nursing saying of: “discharge planning begin on admission” – but what I would like to focus in on is not big picture discharge planning, but day-of discharge planning. Meaning, you’re the patient’s primary nurse and he or she is going home today. What do you do?

Let’s go over what you practically need to do get your patient successfully discharged during your shift, whether that means to their home, an extended care facility (ECF), rehab, skilled nursing facility, or somewhere else. A successful discharge includes everything from timing to transportation and even prescription help with the Hippo app.

Discharge Planning Tips for New Nurses

Click on any link below to jump to that portion of the discharge tips.

Assess the needs

Figure out during report which patients are being discharged and ask some specific questions, either directly to the patient, the off-going nurse, or by looking in the chart.

  • Where will they be discharged to?
  • Are there any tests (labs, x-rays, scans, evaluations) that are must be completed before discharging
    • For example, the patient may be a possible discharge pending a transthoracic echocardiogram, chest x-ray, follow-up basic metabolic panel (BMP), or some other test.
  • Will they need anything set up?
    • Home care, in-home therapy, DME (stands for durable medical equipment, so things like walkers, shower chairs, blood glucose monitoring supplies)
  • What kind of transportation will they have?
  • Are there any financial concerns?
  • Do they need any extensive teaching?
    • Patients going home with a blood sugar monitor for the first time, on a new blood thinner, after a major surgery, or with a new diagnosis like congestive heart failure will require more time to educate them and answer question than others

Knowing these things early in the shift are important because they can really impact your time management. You may need to expedite tests in order to facilitate a timely discharge, need to set up transportation, get specific orders from the physician, and so forth.

The Inevitable Question

“So, the doctor said I may go home today. What time will that be?”

Without fail, almost every single patient being discharged wants to do know when. I completely understand, however it’s not that straight forward.

For patients to get discharged, the attending physician must write discharge orders.  This means they’ve got to sit down and put all of the medication orders in correctly, sign any printed prescriptions for narcotics, and a few other things.

My go-to answer is something like this:

“So, to get you discharged, the physician has to enter quite a few things into the computer. Things like follow-up appointments, specific things they want you to do or not do, medication changes, prescriptions, and more. Once this has been done, I can complete your discharge. Typically, I tell patients to plan for an early afternoon discharge. This gives the physician time to decide on and enter the information. Sometimes it happens earlier, but mentally planning for an early afternoon discharge time is the most realistic.”

If people are looking for a specific time to facilitate a ride, I’ll tell them between 2-3pm.

Physicians typically round on ALL of their patients, then sit down and write discharge orders. What I see happen a lot is the physician rounds around 9:00 am or so and says they can go home, but doesn’t usually put discharge orders in until around 1:00 pm.

By telling people between 2-3pm, that gives me enough time to compile the discharge paperwork, correct any errors, address any deficits, facilitate prescriptions, and balance it with my other patients discharging the same day as well.

It is especially important to give yourself ample time if a patient is being discharged to another facility and is being transported by ambulance, medic, or some other transportation service.

Work with your team

With discharge planning, I typically rely heavily upon my case managers.  They’re amazing getting things set up with facilities, DME, etc.

Also, for a patient to get things like outpatient physical therapy and/or occupational therapy, some forms of DME, or to go to a specific type of facility (like rehab), CMS requires there to be a note from therapy saying the patient requires such. Therefore, touch base with your physical therapist and occupational therapists and read their notes to get a better idea of what they’re recommending for your patient.

Tip: if your patient says hey want something specific (a cane, walker, shower chair, to go home and not rehab or vice versa) look at the latest notes from physical and/or occupational therapy and see what they recommend.

Also, make sure to check out the latest notes from case management (CM) and social work (SW) as well. They typically document any facilities they’ve sent referrals to, if the patient has been accepted, who you need to call report to, the time of transportation, etc. Don’t make my rookie mistake of calling CM or SW before simply looking in the chart! It can save you (and them) time if you take a look at their notes before paging/calling.

Think about transportation

Asking about this first thing will save you quite a bit of headaches. Sometimes, the person who will bring them home is already sitting in the room, but most likely they’re going to have to call for a ride. Maybe their ride can only come during a certain period of time, or only after a certain time, or can’t come at all and we’ve got to find a ride.

I’ve gotten everything together for a discharge, only for the patient to tell me (at 5:00 pm after CM has left for the day) that they have no way home. I’ve also been ready to discharge a patient and they tell me they can’t get a ride until tomorrow.

Ask early so you can plan appropriately!

Paying for prescriptions

This can be another big headache if you haven’t asked the right questions or planned for it. Multiple times, I’ve created all of my discharge instructions and the patient is ready to walk out the door and suddenly they tell me they can’t afford their prescriptions. This even happens at 4:30 pm when I barely have time to get a hold of CM or SW to let them know. This delays discharge because I can’t just quickly get someone to the bedside to address the issue, especially if it’s late in the day.

There is one really easy thing you and the patient can do when paying for scripts is a concern – use the Hippo app. Basically, it will tell you what the cost of the medication is at various pharmacies in the area so you can go to the cheapest one.

Medication can costs vary widely from pharmacy to pharmacy.

For example, a medication that I frequently discharge patients on is metoprolol tartrate (Lopressor). After a quick search, I can see that it costs anywhere from $3.89 to $26.95 for a 60-pill 25 mg tab supply in my area. Another medication frequently prescribed is warfarin (Coumadin), which costs anywhere from $2.78 – $27.14 in my area for a 30-day supply of 2.5mg tabs. Atorvastatin (Lipitor) is anywhere from $6.25 to $95.91 for a 30-day supply of 10 mg tabs.

Go to the wrong pharmacies and you could spend as much as $150 for those 3 scripts, but go to the right ones and your bill would be closer to $12.92. It may require going to a few difference pharmacies, but it can result in exponential savings.

This can make a huge difference for a patient as we all know cost is a huge barrier for many individuals. This also makes the patient a more informed consumer of health care. They know where they can get their medications for the best price and have that dialogue with their primary care provider in the outpatient setting as they require refills and are on medications long term.

The Hippo app is easy to use, signing up is a breeze, and it saves your previous scripts.  If your scrips are at another pharmacy, you can request them to be transferred all within the app as well.

As the discharging nurse, what’s important is making sure which prescriptions your patients wants where and ensuring the physician either e-prescribes them to the correct location or you do that yourself per your facility’s policies.

Once the patient or their loved one picks up their medication, they just show their Hippo card (in the app, pictured below) to the pharmacy staff on checkout.  And that’s it!

Check it out on iTunes.

Discharge Planning Tips for New Nurses

Completing paperwork

Make a list and check it twice.

Seriously.

There are typically quite a few things you have to enter into the computer for the patient, but also for your documentation as well. Care plans need to be closed out, education needs to be resolved, IVs and telemetry need to be removed and documented, documentation requirements need to be met (like core measures), the next dose due for each medication needs to be indicated, and more.

If the patient is being transferred to another facility, even more needs to be completed. These things include calling report to the receiving facility, printing and faxing additional paperwork, printing information for whomever is transporting the patient, and so forth.

Write yourself a little list and check it off as you complete tasks so that you do not forget them.

Giving discharge instructions

Before sitting down to give instructions, double check that the information is correct, paying particular attention to follow-up appointments, medication due times, prescriptions, and any important teaching points that need to be included.

Going over instructions can be pretty overwhelming for patients and should not be rushed. If you’re able, grab a chair and sit down next to them. That lets the patient know you’re not just going to quickly go through it and run out the door (even if that’s what you want to do!) and allows them to more time to ask clarifying questions without feeling like a burden or bother.

Remember the potential mental state of someone going home from the hospital: they may be overwhelmed, excited, sad, tired, scared, or any combination thereof. Therefore, make sure all important information is written down. They will forget a lot of what you talk about during discharge instructions and you must have something to refer back to.

And finally, make sure you have included phone numbers for follow-up questions. They need to have the phone number of someone they can call with concerns both during and after office hours.  This will prevent follow-up phone calls to the nursing unit, but also will facilitate the patient speaking to their physician’s office – which is who they should be speaking with for follow-up questions and/or concerns.

To summarize

Assess needs early on so you can manage your time while addressing their needs, provide realistic expectations related to timing, leverage your healthcare team, ensure transportation is secured, make sure they can afford their prescriptions, make sure your paperwork and documentation is complete, and take your time while giving discharge instructions.

It sounds like a lot, but you will get used to the process and develop your own discharge routine!

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