Strategy 4: Care Transitions from Hospital to Home: Ideal Patient Hospital Discharge Plan

Studies show that when patients are engaged in their healthcare, it can improve their safety and quality of care. To encourage higher engagement, the Agency for Healthcare Research and Quality created the Guide to Patient and Family Engagement in Hospital Quality and Safety. This tested, evidence-based resource helps hospitals collaborate as partners with their patients and their families to enhance the safety and quality of care.

The Guide to Patient and Family Engagement in Hospital Quality and Safety can be applied to hospital discharge planning since patients, and their families are heavily involved in the transition from hospital to home. Engaging patients and their families in hospital discharge planning lowers the chance of harmful events and readmissions. Therefore, it is essential to thoroughly transfer information from clinicians to patients and their families in order to make the transition safe and effective.

Strategy 4: IDEAL Discharge Planning underlines key factors of incorporating the patient and family in discharge planning.

• Include the patient and family as full partners in the discharge planning process
• Discuss with the patient and family five key areas to prevent problems at home:
  • Describe what life at home will be
  • Review medications
  • Highlight warning signs and problems
  • Explain test results
  • Make follow-up appointments
• Educate the patient and family in plain language about the patient’s condition, the discharge process, and next steps at every opportunity throughout the hospital stay
• Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s care to the patient and family and use teach back.
• Listen to and honor the patient and family’s goals, preferences, observations, and concerns.

Strategy 4: IDEAL Discharge Planning Implementation Handbook gives an overview and analysis of the IDEAL Discharge Planning strategy. The handbook’s step-by-step guide shows hospitals how to implement this Patient hospital discharge strategy into place and fix common challenges. Access the PDF version here.

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