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Patient Discharge Care Planning

Patient Discharge Care Planning

An effective discharge plan is often associated with a number of common procedures and activities along the path of care. These procedures include preparing on the day of admission, detailed and accurate records, reviewing assessment information, and estimating the date of discharge based on the standard care pathway. At least 48 hours before discharge, the healthcare team needs to prepare for the patient’s discharge by initiating referrals to social care agencies, community healthcare providers, and contact agencies responsible for installing equipment the patient may need. The next two steps are discharging the patient and follow-up. This paper will discuss a case scenario of a college student who sustained serious injuries following a hit-and-run road accident. The importance of care coordination during the patient’s discharge is the main focus of this paper.

How the Interprofessional Team Will Use HIT To Provide A Longitudinal, Patient-Centered Care Plan Across The Continuum Of Care

Hospital readmission rates have gained a lot of attention in the recent past because they are a reflection of the healthcare system’s efficiency, patient care quality, and performance (McIntyre et al., 2016). An effective discharge plan is critical for the improvement of care continuity between the patient and the healthcare facility so as to improve the health of the patient and minimize the possibility of readmission. Continuity management plays a significant role, more so in complex clinical diseases that need a multidisciplinary team to manage the treatment of a patient. Hence, a well-defined discharge planning system is critical for the facilitation of continuity management and provision of security and predictability in the patient’s future care (Henke et al., 2017).

In this case scenario, a Longitudinal Care Plan (LCP) can ensure that the patient discharge process goes on with no setbacks and the best possible patient outcomes. According to Burt, Rick, Blakeman et al. (2014), an LCP is an integrated, dynamic, and holistic plan that documents the significant disease prevention and treatment plans and goals. An LCP is patient-centered and reflects the preferences and values of the patient, and depends significantly on bidirectional communication. The different elements of LCP can be pulled together by electronic systems to dynamically create a view appropriate and relevant to the patient, family, or healthcare provider, in addition to providing actionable information in identifying and achieving the wellness and health goals of the patient along the care spectrum. The discharge plan will have four parts that will be fulfilled when caring for the patient. These four parts are the assessment of the patient, discharge plan development, service provision, which will include patient/family education and referral service, and evaluation/follow-up.

HIT Elements The Team Members Will Use

The HIT elements that will be used in the discharge plan will include the reason for discharge. The summary will have a description of the presenting condition and the initial presentation to the admission, including the initial diagnostic evaluation description (Wimsett, Harper, & Jones, 2014). In this case, the patient was a hit-and-run victim, and all sustained injuries on admission should be recorded in the discharge summary. The second element will be the significant findings which is the description of the events that occurred to the patient during their stay at the hospital (Wimsett, Harper, & Jones, 2014). A description of the medical and surgical experience of the patient will also be included. Additionally, a description of each of the patient’s surgeries, technical, non-invasive, invasive, and diagnostic procedures, will be described as well. The third element will be the patient’s discharge condition and which will give a sense of the manner in which the patient is fairing (Wimsett, Harper, & Jones, 2014). The payment model upon discharge will also be noted for reimbursement tracking by the insurance company. Another element will be an instruction to the patient’s family and, where appropriate, instructions to the patient as well (Wimsett et al., 2014). The instructions will include discharge medications, therapy orders, activity orders, a plan for medical follow-up, and dietary instructions. The nurse will be tasked with educating the patient and the caregivers (the aunt and uncle) on medication adherence, therapy, how to care for the wounds, physical care, and diet, among others. The attending physician will sign the document. This is useful in the continuity of care, especially because the patient is from a different state from where she got treatment. When she returns to her home state, the physician attending to her will be able to liaise with the current physician if need be, as the name and signature will be displayed in the discharge summary.

How The Interprofessional Team Members Can Utilize The HIT Elements To Prevent Readmission

The interprofessional team can utilize the HIT elements to avoid readmission of the patient by first reading the discharge summary and confirming the information therein is accurate. The healthcare team should incorporate evidence-based practice into the standardized procedure, daily protocols, and EHR as tools for information gathering, provision of feedback, and supporting clinical decisions. In this case scenario, the team will identify the complex and social needs and also obtain post-hospital care after discharge. In this case, the patient has a student insurance cover and is not financially stable. However, the healthcare team can help her obtain primary care and other services she will need through free drug assistance programs and free clinics.

The team will also offer individualized medication reconciliation and education, emphasize the warning signs, and schedule follow-up appointments with home-state community physicians. The team will ensure that the patient and her kin understand the post-charge instructions and also follows the same, obtain care that is appropriate, and know when to look for help. Some of these interventions will call for new roles to be created for pharmacists and nurses and promotion of the use of care coordinators and hospitalists in the management of the patient’s needs.

In addition, the care team will follow up with the patient after discharge. Nurses will call the patient using telemonitoring devices. The hospital needs to take advantage of its formal and informal relationships with health plans, community physicians, among others, in coordinating the care of the patient in the two different states. The hospital’s membership in an integrated health system can decrease the chances of readmission through an emphasis of the system on preventive and primary care and enhanced communication and information flow, such as through shared EHRs among the inpatient and outpatient care providers.

How The Use Of These Elements Will Support Care Coordination

The use of these elements will ensure that patient readmission is avoided at all possible levels. The patient needs to recover without slipping back to negative health outcomes. When each team member is aware of the patient’s needs post-discharge, they will each carry out their duties as expected. The nurses, for example, will be charged with educating the patient and her kin on what to do and what to avoid. The nurses will also know how often and when to call and check up on the patient. The physician will contact the physician who will take over the patient’s care when she returns home. Also, because the patient has had several surgeries, it is important that the nurses ensure she gets frequent attention and observation from a local physician and thus the need to call and communicate often with the patient and her kin. Because the aunt and uncle to the patient will be the persons receiving instructions and not the patients’ family back in her home state, the nurse will have to ensure that the uncle and aunt understand clearly, all the instructions and repeat the same to the patient’s parents. Once back home, the nurses will talk the parents through the instructions to ensure they understand what is required of them in caring for the patient.

Data Reporting in Care Coordination, Care Management, Clinical Efficiency, And Interprofessional Innovation In Care

The patient, in this case scenario, is likely to have multiple providers, and hence, it will be critical to have data on which provider is responsible for the diagnosis ordering of particular imaging or labs. Based on the role of the provider’s specialty, one may have greater dominance in offering care. The dominant physician will be the contact person in case any clarification on the patient’s condition is needed.

The second data set will be on the medications that the patient is prescribed. The patient is likely to be on opioids and will need to be weaned away from the same. All medications administered to the patient, the duration she has taken the specific medication, the expected amount of time it will take for the patient to remain in admission, and thereafter will be useful information. This will monitor any possibility of opioid substance abuse (Substance Use Disorder is a serious epidemic, and the patient should be monitored to prevent her from becoming part of the statistics) (Neuman, Bateman, & Wunsch, 2019). Payer claims and the dates for the next prescription refills will also be included.

After discharge, the patient’s visits to the new physician in her home state will need to be filled in electronically. This will determine if the patient is taking care of herself and if the progress she makes is recorded. When gaps exist in the care provision by the same specialist, it may represent more than just the use of out-of-network ancillary services or changing care providers; hence, the electronic records will enable closer monitoring.

Evaluating Data Quality

The goal of monitoring and evaluating the data is documenting progress towards the objectives and goals in improving the patient’s health. Several metrics will be evaluated in measuring the quality of the data collected. These metrics are the ratio of data to errors, that is, how many errors are present in relation to the data set available; the number of empty values as this is indicative of missing information in a data set; error rates of data transformation occurring as data is converted into different formats; the amount of dark data which is the unusable data because of quality problems in the data; and the data time-to-value which is the amount of time it takes for the healthcare organization to get value from the data information of the patient.

How Information Collected From Client Records Can Be Used To Positively Influence Health Outcomes

The lab data information can be used in critical clinical decisions for the patient’s treatment. The order set in the patient’s EHR record will help in the standardization of her care even after she moves to her home state. The prescribing feature in the system will enable the physician currently taking care of the patient to keep track of the medications that the patient has taken and is currently taking, and this will mitigate any possible medication errors, including opioid drug misuse. Lastly, the nurses caring for the patient will easily know and keep track of records of the patient’s vitals such as blood pressure, family history, drug and food allergies, and chronic diseases, among others, and which can be shared via the patient’s PHR and used in whichever healthcare facility she goes for medical assistance.

Coordinating Individual Findings In The Collaborative Use Of HIT

Communication is the key to coordination among the individual findings of the team members (Morley & Cashell, 2017). When the team meets, each member will need to articulate any changes they observed in the patient, whether positive or negative. The team will also give their opinions on the way forward based on the information they have. The suggestions made need to be evidence-based and which will give positive outcomes. This feedback will also need to be timely and accurate (Garrett, 2016). To ensure that the latter is achieved, the hospital will have dedicated channels of communication such as the intranet, a whiteboard detailing daily patient progress, and a chat room where staff will share thoughts and brainstorm on the patient’s improving health condition and well-being.


Hospital discharge is described as the point at which the end of inpatient hospital care is achieved and the subsequent transfer of ongoing care to other domestic, community, and primary environments. Hence, hospital discharge is not the peak point, but instead, it is one that involves several transitions with the care journey for the patient. The transitional care organization and provision typically involves several social care partners who need to work in coordination in their areas of specialty so that a patient receives safe, and integrated care. The inherent coordinating complexity involving multiple social and healthcare actors, often based in specific organizations, results in the view that hospital discharging can be a high-risk, time-dependent, and vulnerable episode. To avoid readmissions, the healthcare team discussed in this paper will need to work with the patient, her uncle, and aunt, and with her parents once she goes back to her home state. Follow-up on her care will be critical to her successful recovery. The nurses and physicians will have to liaise with the primary care physician at the patient’s home state, utilize data recorded in the patient’s EHR, and coordinate with relevant social structures for the patient to achieve optimal health outcomes.


Burt, J., Rick, J., Blakeman, T., Protheroe, J., Roland, M., & Bower, P. (2014). Care plans and care planning in long-term conditions: a conceptual model. Primary health care research & development15(4), 342-354.

Garrett Jr, J. H. (2016). Effective perioperative communication to enhance patient care. AORN journal104(2), 111-120.

Henke, R. M., Karaca, Z., Jackson, P., Marder, W. D., & Wong, H. S. (2017). Discharge planning and hospital readmissions. Medical Care Research and Review74(3), 345-368.

McIntyre, L. K., Arbabi, S., Robinson, E. F., & Maier, R. V. (2016). Analysis of risk factors for patient readmission 30 days following discharge from general surgery. JAMA surgery151(9), 855-861.

Morley, L., & Cashell, A. (2017). Collaboration in health care. Journal of medical imaging and radiation sciences48(2), 207-216.

Neuman, M. D., Bateman, B. T., & Wunsch, H. (2019). Inappropriate opioid prescription after surgery. The Lancet393(10180), 1547-1557.

Wimsett, J., Harper, A., & Jones, P. (2014). Components of a good quality discharge summary: A systematic review. Emergency Medicine Australasia26(5), 430-438.


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Patient Discharge Care Planning

Prepare a written analysis of key issues, 6–7 pages in length, applicable to the development of an effective patient discharge care plan.

The Institute of Medicine’s 2000 report To Err Is Human: Building a Safer Health System identified health information technology (HIT) as one avenue to explore to reduce avoidable medical errors. As a result of the IOM report and suggestions for patient advocacy groups, health care organizations are encouraged to act by utilizing HIT to improve patient quality and safety.

Health care organizations determine outcomes by how patient information is collected, analyzed, and presented, and nurse leaders are taking the lead in using HIT to bridge the gaps in care coordination. This assessment provides an opportunity for you to analyze the effects of HIT support, data reporting, and EHR data collection on effective care planning.

Patient Discharge Care Planning

Patient Discharge Care Planning


By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 1: Apply care coordination models to improve the patient experience, promote population health, and reduce costs.
    • Explain how HIT can be used to provide a longitudinal, patient-centered care plan across the continuum of care.
  • Competency 2: Explain the relationship between care coordination and evidence-based data.
    • Describe ways in which data reporting specific to client behaviors can shape care coordination, care management, clinical efficiency, and interprofessional idea development.
  • Competency 3: Use health information technology to guide care coordination and organizational practice.
    • Explain how information collected from client records can be used to positively influence health outcomes.
  • Competency 4: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
    • Write clearly and concisely, using correct grammar and mechanics.
    • Support main points, claims, and conclusions with relevant and credible evidence, correctly formatting citations and references using APA style.
Marta Rodriguez, a student, recently moved from New Mexico to Nevada to live with her aunt and uncle and was enrolled as a freshman in college. While attending her first semester, Marta was involved in a hit-and-run car accident. She was transported to the nearest shock trauma center where she spent the next four weeks undergoing multiple surgeries and antibiotic treatment for a systemic infection. Spanish is Marta’s first language and English is her second. Marta has a student health insurance plan.You are the senior care coordinator overseeing Marta’s care. You will be presenting her case to the interdisciplinary team members who are caring for Marta at an upcoming meeting to consider key aspects of a successful and safe discharge care plan for her. You are expected to lead the discussion, focusing on the role of informatics in effective discharge care planning, and have decided to prepare an analysis of key issues for team members to consider, which you will distribute to the attendees for review prior to the meeting.Note: Remember that you can submit all or a portion of your draft to Smarthinking for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.

Analyze key issues for consideration at the discharge planning meeting. Determine the effects of HIT support, data reporting, and EHR data collection on effective care planning.

Written Analysis Format and Length

Patient Discharge Care Planning

Patient Discharge Care Planning

Use the following template for your written analysis:

  • APA Style Paper Template [DOCX].
Analyzing Key Issues
The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your analysis addresses each point, at a minimum. You may also want to read the Patient Discharge Care Planning Scoring Guide to better understand how each criterion will be assessed.

  1. Explain how the interprofessional team will use HIT to provide a longitudinal, patient-centered care plan across the continuum of care that supports Marta in the discharge planning process.
    • What HIT elements will the team members use and why?
    • How can the interprofessional team members utilize the HIT elements to prevent a readmission of this patient 48 hours after being discharged?
    • How will the use of these elements support the coordination of care for this patient?
  2. Describe at least three ways in which data reporting specific to client behaviors can shape care coordination, care management, clinical efficiency, and interprofessional innovation in care.
    • How would you evaluate the quality of the data?
  3. Explain how information collected from client records can be used to positively influence health outcomes.
    • How will the interprofessional team members coordinate their individual findings in the collaborative use of HIT?
  4. Write clearly and concisely, using correct grammar and mechanics.
    • Express your main points and conclusions coherently.
    • Proofread your writing to minimize errors that could distract readers and make it more difficult for them to focus on the substance of your analysis.
  5. Support main points, claims, and conclusions with relevant and credible evidence, correctly formatting citations and references using APA style.
    • Is your supporting evidence clear and explicit?
    • How or why does particular evidence support a claim?
    • Will your audience see the connection?

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