Transition (Discharge) Planning

Preparing for an efficient and effective path to discharge begins at admission. Some admissions involve standardized interventions and predictable outcomes, with discharge dates and dispositions unfolding as expected. However, many inpatient encounters are complex and require coordinated multidisciplinary planning to facilitate safe and timely transitions. In addition, collaborative post-discharge support can reduce rates of unnecessary early re-admissions.

Connect Care provides decision and documentation supports that can help clinicians with complex discharges, while improving communication with health care teams continuing care after discharge.

RAPID Rounds

"Rapid" (Review, Assess, Plan for Immanent Discharge) rounds is a CoACT Collaborative Care activity that fosters communication within and between care team members, including patients and/or families. It facilitates timely coordination and collaboration that both improves the quality of care and decreases overall lengths of stay.

Connect Care provides a number of informational supports for Rapid Rounds, including:

  • Rapid Rounds Patient List - for use during multidisciplinary discharge planning rounds to facilitate rapid information access and decision documentation while quickly reviewing a panel of inpatients. The list gives access to a succinct summary of information relevant to care transitions together with interactive tools for updating how multidisciplinary services contribute to discharge readiness.

  • Transition Planning Sidebar - for use during patient care when a chart is opened to an inpatient encounter. This replicates much of the information found in the patient list report, focusing on information that can be best used and updated during day-to-day care.

Transition Planning Report

When a patient (row) is selected in a Rapid Rounds patient list, a "report" displays either below or to the side of the list (user preference). The default such report for Rapid Rounds Patient Lists is a transition planning report. It is interactive. Any heading or subheading can be selected to open a popup for viewing or editing relevant information.

Transition Planning Sidebar

A rightward "sidebar" displays whenever a patient chart is opened to an inpatient encounter. This has a link index at the top that allows rapid switching to more specific sidebar reports, including a "Planning" report that focuses on transition planning supports.

  • Tip: Transition Planning Sidebar

  • Demo: Transition Planning Sidebar

Discharge Barriers, Delays and Milestones

Rapid Rounds and Transition Planning information tools help multidisciplinary teams to recognize, record and manage the steps of discharge planning. This includes key events that should occur at specific intervals before an anticipated transition (milestones), early identification and resolution of barriers to an anticipated discharge and flagging any last minute (unanticipated) glitches that delay a planned discharge.

Transition Milestones

Milestones are key events, such as patient education or after-visit summary preparation, that should occur as part of all discharge or transfer pathways.

Transition Barriers

Barriers are patient-specific considerations that delay progression through expected discharge milestones and readiness for discharge. Barriers often require additional coordination or consultations to be resolved. For example a discharge barrier might be when a Patient requires home oxygen assessment and qualification assessment by a Respiratory Therapist.

Transition Delays

Delays typically affect a discharge or transfer process that has already been approved, requested (ordered) and initiated. The Safe Discharge Checklist and all discharge milestones are complete; but the patient’s departure is postponed in a way that continues to occupy an acute care bed. The reason for transition postponement is the "delay." For example a patient's needed transportation may not arrive or occur when needed.

Transition Planning Documentation

Use of any of the above tools generates patient and encounter-level data that is pulled into Connect Care's provincial documentation templates, including discharge and inter-facility transfer summaries. The "Advanced" variants of these templates allow the user to select transition information summaries appropriate to different levels of complexity.

Readmission Risk

Plentiful evidence shows that patients with multiple comorbidities, frequent emergency room visits or other frailty indicators are more likely to present for readmission to hospital within a short time following their last discharge. Many of these readmissions are preventable, mostly through anticipation, communication and provision of post-discharge supports.

AHS uses the "LACE readmission risk index" to stratify patients into those who are at low, moderate or high risk for early readmission. The index considers the patient's length of stay, admission type, comorbidities and frequency of emergency room visits.

Automated Calculation

Most of the information needed to calculate a LACE Index is available to Connect Care in-system, and does not need to be entered by prescribers. Accordingly, an automatically calculated LACE Index is continually updated for all inpatients.

Location

The automated LACE Index can be found and used in a variety of ways:

  • Inpatient Chart Sidebar

    • A rightward sidebar is present when any chart is opened to an inpatient encounter. The default view includes "Checklists" as well as a "Transition Planning" section that includes the current LACE Index.

    • The sidebar has an index at the top, which includes an item for "Planning". This can be selected to bring more transition planning tools into the sidebar, such as the "Transition Planning" section that includes the LACE Index.

  • Rapid Rounds Patient List and Report

    • Inpatient care teams may support Rapid Rounds with Connect Care tools that facilitate discharge planning. These include a Patient List template with columns summarizing key information affecting discharge readiness, including the LACE Index.

    • Rapid Rounds lists typically show a "Rapid Rounds Report" when a patient row is selected. This report also displays LACE Index information.

    • The same Rapid Rounds report can be viewed from the Transition Planning section of the inpatient sidebar.

  • Discharge Summative Documents

    • LACE Index values are included in the Basic and Advanced provincially standardized discharge summary templates in the "Follow Up Arrangements" section.

  • SmartLink

    • The ".LACEINDEX" SmartLink can be used to pull LACE information into any inpatient documentation.

Interaction

All of the above LACE Index inclusions are interactive. Selecting the "LACE" label will open a pop-up display that contains information about how the index was calculated, what in-system data was used, and how the index might be interpreted to guide discharge planning.

Validity

The comorbidities component of the LACE Index calculation is sensitive to whether a patient chart complies with minimum use norms. It is essential that a patient's chronic illnesses be documented in the problem list and/or medical history sections of the chart. If a particular LACE Index seems inappropriately low, be sure to confirm that the patient's comorbidities are appropriately reflected in the problem list and medical history. The LACE pop-up report (accessed by selecting the LACE label wherever it appears) includes summaries of relevant in-system data.

Manual Calculation

The LACE pop-up report includes a link to a pop-up flowsheet that can be used to manually calculate a LACE Index. Manual calculations can help validate Connect Care's automated calculation. The LACE flowsheet is also available in the Flowsheets activity.

Resources