Transition (Discharge) Planning

Preparing for an efficient and effective discharge begins at admission. Some admissions involve predictable interventions and outcomes, with dates and dispositions unfolding as expected. Others are complex and require coordinated multidisciplinary planning to facilitate safe and timely transitions. In addition, well-planned post-discharge supports can reduce unnecessary re-admissions. 

Transition Care Plan

Transition planning is facilitated by a shared transition care plan. This includes consideration of a patient's health and social needs prior to admission, how changes occurring during an admission affect requirements for a safe and timely transition to the next health care setting, and how ongoing needs can best be addressed after discharge. Transition care plans are team plans. Ideally, they reflect consensus building among participating disciplines and clinicians.

Transition Planning Package

Connect Care provides multidisciplinary decision and documentation supports that can help clinicians with complex discharges, while improving communication with healthcare providers picking up care after discharge. These tools comprise a "transitions planning package" that includes:

Transition planning is among the meaningful use norms that all inpatient prescribers should comply with. This section explains how facilitative tools work, with links to tips, guides and demonstrations:

Admission and Discharge Navigators

An Admission Navigator promotes sequential attention to what matters most for a safe transition to hospital. This includes problem, medication and adverse reaction reconciliation, history taking and admission orders. Indeed, use of the admission navigator initiates data capture that then flows through daily care to discharge documentation. The Discharge Navigator picks up information entered at admission while highlighting changes that have occurred in hospital, exposing this for effective discharge documentation and communication.

Expected Discharge Date

An Expected Discharge Date (EDD) section is prominent near the top of the navigator. This allows a rough estimate to be entered, along with any early observations about factors that might affect. The EDD is then continually revised throughout the admission. When active medical issues have been addressed as far as possible, the patient's level of care is adjusted to "Alternate Level of Care" (ALC). This ALC status is normally initiated at the time of a revised EDD if the patient cannot be discharged on the actual EDD.

Checklists

Transition planning checklists appear in the default inpatient Sidebar views that show when any inpatient chart is opened. The lists are grouped by admission, daily and discharge tasks. The same lists can be accessed within patient lists (an available list report) and as a chart activity (global search for "checklist"). The default sidebar has a transition planning section that summarizes discharge readiness information with embedded links for just-in-time access to the same data managed through rapid rounds and other transition planning tools. A dedicated discharge planning sidebar can be accessed from the inpatient sidebar index (top of sidebar), giving additional access to all of the information found in the transition planning report.

RAPID Rounds and Transition Planning

"Rapid" (Review, Assess, Plan for Imminent Discharge) Rounds is a CoACT Collaborative Care activity that fosters communication within and between care team members, including patients and families. It facilitates timely coordination of care and decreases overall lengths of stay. Among other things, Rapid Rounds are used to validate Expected Discharge Dates. 

Even if formal Rapid Rounds are not practical for a particular inpatient ward, the associated transition planning tools can be used by clinicians to facilitate discharge planning. This might occur in team conferences or other planning venues.

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

Rapid Rounds Patient List

Patient lists serve as a gateway to inpatient workflows in Connect Care. A uniquely interactive list has been developed to support Rapid Rounds. This exposes information needed for discharge planning while allowing much of it to be updated in-context without leaving the patient list.

Rapid Rounds 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 report for Rapid Rounds lists is a transition planning report. It is interactive; any heading or subheading can be selected to open a pop-up for viewing or editing relevant information.

Transition Planning Sidebars

Discharge 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 supports rapid switching among more specific sidebar reports, including a "Planning" report that exposes transition planning supports.

These sidebar displays replicate much of the discharge planning information found in Rapid Rounds tools. In addition, the "Discharge Planning" title within the sidebar can be selected to open the Rapid Rounds Transition Planning Report.

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.

Discharge 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.

Discharge 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 is waiting on confirmation of a flight time for a repatriation to a northern community.  

A discharge barrier is differentiated from a discharge delay by the time frame in which it occurs. Barriers occur at any time during a patient inpatient journey and prevent completion of the Safe Discharge Checklist or progression through discharge milestones. A patient has not achieved readiness as long as unresolved barriers remain.

Discharge 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 discharge delay might be recorded when there is a confirmed time for a repatriation flight but weather prevents the flight from leaving on time.

A discharge delay is differentiated from a discharge barrier by the time frame in which it occurs. Delays occur at the end of a patient journey and are used when a discharge is initiated but departure is postponed. Recording a delay begins a timer, which is displayed for bed planning teams to track, in minutes, how long a patient’s discharge has been delayed. 

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 and the LACE Index

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:

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.

Discharge/Transfer Documentation

All transition planning tools work together to manage a core data set that can be automatically incorporated into discharge communications, saving providers time and hassle. Provincially standardized discharge summaries are available via the inpatient sidebar ("Notes" section from index). These pull in the products of multidisciplinary planning. The writer can select from options for simple (no change), moderate or advanced (complex) transitions.

Resources