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Health Services (North)Nursing Foundations

Discharge Planning

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Content

• What is discharge Planning?• The multidisciplinary approach• Why is effective discharge

planning so important?• The discharge planning process.• Research Activity-

- Community Resources available for the elderly - Health Coaching

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Discharge Planning

• What is discharge Planning

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Discharge Planning

• Discharge Planning is the quality links between hospitals ,community-based services, non- government organisations and carers.

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Discharge Planning• Effective discharge planning

supports the continuity of healthcare, between the health care setting and the community, based on the individual needs of the patient.

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Discharge Planning

• It is described as "the critical link between treatment received in hospital by the patient, and post-discharge care provided in the community.“

Discharge Planning Association Inc,2009

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Discharge Planning

• Who needs to be involved in the discharge planning process?

• Why do we need a multidisciplinary approach?

Group activity

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Multidisciplinary Team Approach• The patient

• Professional carers, family carers• Hospital Multidisciplinary team

including:- Medical staff- Nursing staff- discharge co-ordinator- Allied Health staff e.g. Speech

Therapist, Psychologist, Physiotherapist, Occupational Therapist, Social worker

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Multidisciplinary Team Approach

• ACAT• Community Team• Community Services• Pharmacist• Aged Care Facility• Patient’s regular GP

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Discharge Planning

• When does discharge Planning begin?

• Why does it need to begin at this time? Group Activity

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Discharge Planning Commences at

Preadmission/DischargeAt pre admission/admission we must be thinking about and working on discharge processes to ensure the best possible outcomes and discharge process for our patient.

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Discharge Planning Commences at

Preadmission/Discharge• Liaison with current services already in place particularly with an unexpected/emergency admission

eg have meals on wheels service been cancelled?• Does your patient have a frail partner at home ?• Is your patient actually the carer?• Who is looking after the cat?

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Discharge Planning Process• Risk screening should be performed

early in an admission• Establish if the patient has simple (80%

of patients) or complex planning needs.• A multidisciplinary approach is essential

to effective discharge planning• Discharge date needs to be estimated

early• There needs to be discussion with

patient carer /family

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Discharge Planning Process• Pre discharge education especially

re medications and possible resources required

• Communication with GP in a timely manner

• Discharge summary should be written for the patient with a copy sent to the GP.

• Follow–up appointments arranged• Timely access to support services

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Discharge Planning

• What are the benefits of good discharge Planning?

Whiteboard Brainstorm Activity

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Benefits of effective discharge planning

• Improved patient health outcomes• Reduction in readmission to hospital• Reduces length of stay which is -Cost effective• Reduces error and unnecessary delays

along patient pathway• Reduces pressure on beds therefore

increasing patient throughput

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Effective discharge planning

• Whether we like it or not, the bucket is not bottomless and we must use our health resources in the best most efficient way possible ,whilst not compromising the provision of Quality Healthcare for all.

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Effective Discharge Planning

• How does length of stay impact on Health Funding e.g. in a Private Hospital, case- payments etc.

Class whiteboard Brain-storm activity

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How do we know if discharge planning is successful?

• It is included as an aspect of care which commences on the day of or prior to admission

• It goes beyond the boundaries of the facility

• There has been a multidisciplinary approach

• Ensures all requirements needed to facilitate discharge are in place before or by the estimated date of discharge

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Group Research activity

• Group 1 Research –Health Coaching- as per questions on worksheet

• Group 2 Research ACAT services –as per questions on worksheet

• Group 3-Research-HACC services –as per questions on worksheet

• Group 4-Research-DVA services as per questions on worksheet

• Group 5-Research –EACHP services as per questions on worksheet

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The Continuum of Care

• Let’s review what we have covered in Nursing Foundations so far and pull it all together

Pre admission through to discharge

Class whiteboard brainstorm activity

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References

Discharge Planning :Admission and discharge www.mmhr.org.au WA Country Health Service

Quality and Service Improvement Tools Discharge Planning www.institute.nhs.uk

Hospital Discharge Planning Alison Miller,ehow contributor www.ehow.com/way_5467850_disc herge-planning.html

Hospital Discharge Planning Alzheimer's association www.alz.org