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How to Improve Discharge Planning and Documentation

    Discharge planning and documentation significantly influence patient outcomes and quality reporting by demonstrating the impact of home health services on patient progress.

    Home health organizations should start planning for a patient’s discharge from the beginning of the care, even during the initial intake. This helps set the patient up for success and better outcomes.

    IDEAL Discharge Planning

    The IDEAL discharge planning process has been effective in improving the discharge process in many hospitals. It is also highly recommended for home health settings to achieve improved patient outcomes and better scores in value-based purchasing.

    IDEAL is an acronym that outlines the following important aspects of discharge planning:

    • Include the patient and family as active participants in the planning process.
    • Discuss critical areas with the patient and family to prevent problems at home.
    • Provide clear education about the patient’s condition, discharge process, and next steps.
    • Assess how well clinicians have communicated with the patient and their family using the “teach-back” method.
    • Listen to and honor the patient and family’s goals, preferences, observations, and concerns.

    These elements prioritize health literacy, patient-specific needs, and enhancing the patient experience, aligning with the Centers for Medicare and Medicaid Services (CMS) priorities. The integration of patients and families in all aspects of care, including education, is a crucial part of the Quadruple Aim from CMS.

    What to Do During Visits

    • Teach-back Method – During each visit within an episode of care, clinicians should prioritize patient and family education regarding the diagnosis and medications, utilizing the “teach back” technique to ensure comprehension, as medication misunderstanding is a leading cause of patient readmissions.
    • Progress Report – Regular discussions should occur to assess the patient’s progress toward their care goals, actively listening to the patient’s input and considering the appropriateness of the set goals.
    • Family Involvement – Actively encourage patient and family involvement throughout the entire visit and care process, focusing on educating family caregivers to support the patient during and after the episode of care. Involve family members in discharge planning, assigning them shared responsibilities to ensure a smooth transition and ongoing care for the patient.

    Documenting OASIS-E Discharge

    When completing the home health OASIS-E for discharge purposes, here are some crucial points to keep in mind:

    Accuracy: Ensure that all information provided in the OASIS-E assessment is accurate and reflective of the patient’s condition at the time of discharge.

    Timeliness: Complete the OASIS-E assessment within 2 calendar days of discharge or knowledge of the need to discharge to capture up-to-date information.

    Comprehensive Assessment: Conduct a comprehensive assessment of the patient’s health status, including their physical, functional, and psychosocial well-being. This will involve evaluating their activities of daily living (ADLs), mobility, cognitive status, wounds, medication management, and more.

    Discharge Goals: Document the patient’s discharge goals, which may include improvements in functional abilities, pain management, wound healing, or any other relevant aspects of their care. Include details regarding progress made toward achieving these goals.

    Medication Reconciliation: Ensure accurate and complete documentation of the patient’s medication regimen at the time of discharge. Include any changes made during the home health episode, as well as instructions for ongoing medication management.

    Communication: Note any communication or coordination that took place with other healthcare providers, such as primary care physicians, specialists, therapists, or community resources, to support the patient’s continuity of care.

    Patient Education: Document any education provided to the patient and their caregivers regarding self-care techniques, medication administration, diet, safety precautions, or any other relevant topics. Include details on the patient’s understanding and ability to manage their own care.

    Discharge Disposition: Indicate the patient’s discharge disposition, such as whether they returned to their previous residence, were transferred to another healthcare facility, or had any other specific arrangements made.

    Supportive Services: Identify any supportive services that were arranged or recommended to the patient upon discharge, such as home health aide services, durable medical equipment, or ongoing therapy needs.

    Signatures and Certifications: Ensure that the OASIS-E assessment is properly signed and certified by the appropriate individuals, adhering to the regulatory requirements of your specific jurisdiction.

    The Impact of Proper Discharge Planning and Documentation

    Proper discharge planning and documentation impact value-based purchasing scores derived from OASIS items, patient satisfaction scores from the CAHPS survey, and hospitalizations/ER visits data from claims.

    It is crucial to reflect quality care, patient progress, and positive outcomes in the discharge documentation. Your clinicians should accurately and comprehensively record health status and care outcomes in the OASIS Discharge charting. Your QA program should ensure a clear demonstration of this in the documentation.

    Ultimately, an effective patient discharge and documentation serve as a crucial source of information for continuity of care, facilitating effective communication among healthcare providers and enabling appropriate treatment planning for future healthcare needs. Additionally, it contributes to accurate reimbursement and quality reporting, demonstrating the value and quality of care provided by the home health agency.