Taking care of patients is, of course, a nurse’s main duty. But what happens when that patient is ready to go back home? Discharge planning is critical for preparing the patient to leave the hospital and helps healthcare providers all be on the same page regarding follow-ups and further treatment. Proper discharge planning will also help avoid the need for patient re-hospitalization in the near future.

If you’ve never been in charge of discharge planning, it may seem like a fairly simple role. However, there are a lot of aspects of the role that aren’t often considered. Here are the ins and outs of discharge planning duties.

Referrals

Following initial treatment in a hospital or other facility, a patient may require further treatment with another provider. A discharge planning nurse helps to arrange patient referrals with these services, which may include home care, primary care, physical therapy, and more.

Understand the Procedures

Discharge planning nurses may not have been working directly with the patient during their stay at the hospital. Therefore, this nurse must work closely with the patient’s doctors and nurses to ensure that there is a plan for discharge and that everyone involved knows what they are. They must also discuss these plans with family members of the patient, especially if they have some role to play with regard to the patient’s further healing.

Teaching

When a patient requires further treatment or care following their discharge, family members must often step in to help. In these instances, it is the discharge planning nurse that has the responsibility to teach the family how to perform certain simple procedures necessary for the patient’s health. This could be something like how to properly wrap a wound or how to read a glucometer.

Post-Treatment Preparation

As mentioned above, the discharge nurse is responsible for making sure that the patient has referrals for other healthcare providers whose services may be needed after initial treatment. During this time, nurses need to also ensure that the patient has all of the information and devices that they may need after their discharge. They should also verify that there are follow-up appointments made and that the patient knows when and where those are.

Teamwork

A discharge nurse is not a lone wolf in the hospital; she must work closely with other team members in order to ensure the best care possible. In preparing for discharge, the nurse may hand over certain duties to the patient’s assigned nurse, especially if there are several discharges happening at the same time. The nurse may also need to discuss care and follow-up treatment with the patient’s physician.

Tips for Discharge Planning

If you have come into the role of discharge planning nurse, you may be wondering how to manage this difficult position. There are a lot of things involved and you want to make sure that you’ve followed guidelines and procedures.

When you receive notice that a certain patient is going to be discharged that day, you’ll need to talk with the patient’s nurse and check their chart to see what you need to prepare. You’ll need to consider the following:

Where are they going? Will the patient be returning directly home or to some other care facility? You should know where they are headed and have some type of contact information for that location, whether it’s a family member’s house or a physical therapy clinic. Additionally, you should make sure they have transportation to get there.

What tests need to be done? Has the patient had all of their lab work and x-rays taken? Occasionally, there will be a need for further scans or exams before a patient can be discharged. You’ll need to ensure that these have been done or will be done that day.

Do they need equipment? If the patient is returning home and needs further care, it’s possible that they’ll need medical equipment at home. This could be glucose monitoring items, shower chairs, or a wheelchair. You’ll need to make sure they have this already at their home or that they have a way to get it.

Essentially, the discharge planning nurse serves as a connection between in-patient care and follow-up or out-patient care. They help to make sure that the patient and their family understand exactly what to do after discharge to prevent injury and encourage healing. They are a crucial part of proper patient care.