Use these guidelines to ensure care coordination and discharge plans are effective, timely and appropriate to each patient’s needs
By Debra Wood, RN, contributor
June 8, 2015 – Care coordination and transition management have become the new buzzwords in nursing as hospitals become more concerned with preventing unnecessary hospitalizations. The topic goes beyond discharge planning to incorporate a more holistic, long-term view of patient care.
Susan Russo, RN, MSN, MPT, CCM, recommended clear communication with patients and colleagues when transitioning patients.
“It is about getting the patient the right care at the right time in the right settings,” said Susan Russo, RN, MSN, MPT, CCM, clinical manager at RightCare, a software company specializing in care transitions in Horsham, Penn.
“Patients today being discharged often have more chronic conditions and that provides challenges with their health care,” said Nancy May, MSN, RN-BC, NEA-BC, president of the American Academy of Ambulatory Care Nursing. Those patients are often uncertain about what to do. “The smoother we can make these transitions, the less gaps in care we will have.”
Ensuring patients leave the hospital prepared for the next setting falls to nurses. Suggestions for smoother care transitions include the following:
1. Begin discharge planning at admission. Start with a good assessment about what the patient might need at discharge so there isn’t scrambling at the end, Russo advised. That assessment should include a discharge risk assessment, checking for risk factors such as low literacy or multiple conditions and medications. Planning should continue throughout the stay, The Joint Commission recommends.
2. Know the discharge plan. In some facilities, the discharge planner or case manager will be in charge of developing the discharge plan. In others, the primary nurse will work with the physician on a plan. Participate in daily interdisciplinary team meetings and communicate with case managers or discharge planners continuously to update patients’ status, suggested Mimi Haskins, DNP, RN, CNS, CMSRN, president of the Medical-Surgical Nursing Certification Board.
Janie Schumaker, RN, BSN, MBA, CEN, CPHQ, FABC, advised nurses to never lose sight that they are the patient’s advocate.
Be aware of the plan and work toward making sure each element is addressed. The Institute for Healthcare Improvement (IHI) recommends writing the plan for the day and the scheduled discharge date on a white board in the patient’s room. Do not assume a navigator or someone else created the discharge plan or completed the teaching, added Janie Schumaker, RN, BSN, MBA, CEN, CPHQ, FABC, chief nursing officer of T-System, an electronic medical record company based in Dallas. She emphasized that the nurse must be the patient advocate.
3. Provide thorough patient education. Weave teaching in during every patient encounter, Schumaker suggested. For instance, when administering medications, explain what each drug is and why it was ordered. Talk through a dressing change, explaining each step as you are performing it.
Assess how the patient learns best and tailor educational discussions to play to the person’s strengths. Use simple words, short sentences and no medical jargon, advises the Institute for Healthcare Improvement. Send the patient home with written instructions. If he or she forgets what was said, the paper documentation will reinforce teaching.
4. Use “teach back” to assess patient’s understanding. “Teach back,” asking the patient to restate to you what has been taught, is a proven method for assessing comprehension of information already taught. If gaps are found, the information is presented again and then the patient is given another opportunity to explain it in his or her words. Return demonstrations are valuable when the patient must complete a task, such as a dressing change.
5. Make family caregivers and community agencies full partners in care. Patients often rely on family members to help them transition home. The caregiver should be included in teaching and know how to handle various situations that are likely to come up, and home health nurses can assist with patient transitions.
6. Reconcile medications. Patients must know what medications to take at home and how. Discharge teaching should include not just the new medications but whether to take drugs the patient was prescribed before admission. Make sure the patient has access to the medications and can afford them. Arrange for delivery of the drugs, if needed.
7. Inform patients about when and whom to call with concerns. Patients and caregivers should know warning signs of a worsening condition and whom to call if they are concerned or think it’s an emergency, advises The Joint Commission.
8. Schedule a follow-up visit within 48 hours. Make the appointment for the patient or at least provide clear instructions about whom the patient should follow up with, Schumaker explained. Confirm that the patient has a way of getting to the scheduled appointment. Transportation often presents challenges to appropriate follow-up. May warned that it’s not enough to just set an appointment; the patient has to be able to get to it.
9. Send records to the receiving provider. Send a complete history to the receiving provider, such as the primary care practice, Schumaker said. Often, the electronic medical record system can automatically send that information. Nurses on the unit can call the ambulatory nurse to provide the latest plan of care, May said. If transferring care to another agency, such as home health care, forward the plan and eligible records and be available to answer any questions.
10. Call the patient the next day. Telephone people the day after discharge to answer any questions and make sure the patient is doing as expected at home, Schumaker advised. Likewise, The Joint Commission recommends timely follow up by telephone or in person.
The American Academy of Ambulatory Care Nursing has developed a Care Coordination and Transition Management (CCTM) Core Curriculum, for both acute-care and ambulatory-care nurses. The academy, with the Medical-Surgical Nurses Certification Board, will offer a certification exam in Care Coordination and Transition Management in fall 2015.
References and resources:
Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure. Institute for Healthcare Improvement; 2008.
Transitions of Care: The Need for a More Effective Approach to Continuing Patient Care. The Joint Commission; 2012.
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