1. Health Services (North)
Nursing Foundations
Discharge Planning
Document Title (Editable via ‘Slide Master’) | Page 1

2. 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
Document Title (Editable via ‘Slide Master’) | Page 2

3. Discharge Planning
• What is discharge Planning
Document Title (Editable via ‘Slide Master’) | Page 3

4. Discharge Planning
• Discharge Planning is the quality
links between hospitals ,communitybased services, non- government
organisations and carers.
Document Title (Editable via ‘Slide Master’) | Page 4

5. 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.
Document Title (Editable via ‘Slide Master’) | Page 5

6. 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.“
Document Title (Editable via ‘Slide Master’) | Page 6

7. Discharge Planning
• Who needs to be involved in the
discharge planning process?
• Why do we need a multidisciplinary
approach?
Group activity
Document Title (Editable via ‘Slide Master’) | Page 7

8. 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
Document Title (Editable via ‘Slide Master’) | Page 8

9. Multidisciplinary Team Approach
•
•
•
•
•
•
ACAT
Community Team
Community Services
Pharmacist
Aged Care Facility
Patient’s regular GP
Document Title (Editable via ‘Slide Master’) | Page 9

10. Discharge Planning
• When does discharge Planning
begin?
• Why does it need to begin at this
time?
Group Activity
Document Title (Editable via ‘Slide Master’) | Page 10

11. Discharge Planning
Commences at
Preadmission/Discharge
At 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.
Document Title (Editable via ‘Slide Master’) | Page 11

12. Discharge Planning Commences at
Preadmission/Discharge
• Liaison with current services already in place particularly with
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?
Document Title (Editable via ‘Slide Master’) | Page 12

13. 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
Document Title (Editable via ‘Slide Master’) | Page 13

14. 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
Document Title (Editable via ‘Slide Master’) | Page 14

15. Discharge Planning
• What are the benefits of good
discharge Planning?
Whiteboard Brainstorm Activity
Document Title (Editable via ‘Slide Master’) | Page 15

16. 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
Document Title (Editable via ‘Slide Master’) | Page 16

17. 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.
Document Title (Editable via ‘Slide Master’) | Page 17

18. Effective Discharge Planning
• How does length of stay impact on Health
Funding e.g. in a Private Hospital, casepayments etc.
Class whiteboard Brain-storm activity
Document Title (Editable via ‘Slide Master’) | Page 18

19. 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
Document Title (Editable via ‘Slide Master’) | Page 19

20. 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
Document Title (Editable via ‘Slide Master’) | Page 20

21. 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
Document Title (Editable via ‘Slide Master’) | Page 21

22. 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
Document Title (Editable via ‘Slide Master’) | Page 22