Transition (Discharge) Planning

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

Transition Care Plan

Transition planning is facilitated by a shared plan. This includes consideration of a patient's health and social needs prior to admission, important changes occurring during an admission, and how needs will be addressed after discharge. Transition care plans are team plans. They reflect consensus-building among participating disciplines and clinicians.

Transition Planning Tools

Connect Care provides decision and documentation supports that can help with complex discharges, while improving communication to those continuing care after discharge. These tools comprise a "transitions planning package" that includes:

Good transition planning is key to alignment with the meaningful use norms that all inpatient prescribers should comply with. This section explains how Connect Care's transition planning 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) is prominent in relevant navigators, sidebars and patient lists. This allows a rough estimate to be entered, along with any early observations about factors that might affect. The EDD can be revised throughout an 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 that shows when an inpatient chart is opened. Three checklists group "admission", "daily" and "discharge" tasks. The same lists can be accessed within patient lists (an available list report) and as a chart activity (menu search for "checklist"). Checklists improve awareness of things like EDD documentation requirements, as well as specific actions that should be taken prior to discharge.

Patient Chart Sidebar

The default chart sidebar has a transition planning section that summarizes discharge readiness indicators, with embedded links for just-in-time access to information from rapid rounds and other transition planning activities. In addition, a dedicated discharge planning sidebar can be accessed from the inpatient sidebar index (top of sidebar). This reproduces in the sidebar all information found in the transition planning report.

A shortened "Transitions of Care" planning section appears within the default sidebar that shows when an outpatient encounter is opened. It focuses on current patient support needs and community resources used.

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.

Discharge Readiness ("Traffic Lights")

Alberta Health Services (see Alternate Level of Care) considers a patient "medically ready" for discharge when the primary provider discipline (referred to as "medical" for simplicity) for an inpatient encounter has completed clinical tasks and the patient is dischargeable. Other needs (e.g., further mobility promotion, destination facility readiness, community home care readiness) may delay discharge after a patient is medically ready. Medical readiness may merit a change of in the patient's level of care to "Alternate Level of Care".

Connect Care provides discharge planning tools that can help record determinations about when a patient is medically ready for discharge. Planning for patients with relatively straightforward discharge needs can be facilitated with a simple medical readiness tool. Planning for older or more complex patients is best done with a multidisciplinary readiness tool. The latter facilitates tracking determinations for more than one collaborating healthcare discipline.

Simple Medical Readiness

The Expected Date of Discharge editing tool is enhanced (March 2025) to include a binary button ("Ready Now", "Not Yet Ready") that can be used to indicate whether a patient is medically ready for discharge. The date of determination is automatically recorded. The focus is on "medical readiness" (primary hospital service has completed tasks and patient would be dischargeable from that service, even though other disciplines may need to complete work to enable a safe discharge), as there are no tools for explicitly tracking nursing and allied health readiness.

Complex Medical Readiness

A multidisciplinary discharge readiness planning tool can be accessed from within the Rapid Rounds List (double-click on the Readiness column "traffic light" symbol), Rapid Rounds Report (click on the "discharge readiness" section text) or sidebar transition planning tools (again, click on the "discharge readiness" section text).

A pop-up tool facilitates simultaneous management of multidisciplinary indicators of discharge readiness, expected discharge date (EDD), discharge destination and the level of care. It also provides a space where teams can record discharge planning notes, which can be iteratively updated in a wiki-like fashion.

Safe Handling Readiness

The discharge readiness planning tool includes display of a patient's latest safe handling status (SHS) as well as the target SHS that must be achieved for the intended discharge destination. The 6 levels of SHS (Independent, Minimum assistance, 1 - person assist, 2 - person assist, Sit/Stand with lift, Total lift) are represented with familiar icons. These can be selected to quickly change the current or target SHS.

In addition, a SHS patient list column appears within the Rapid Rounds patient list templates. This shows whether the current status equals or exceeds the target mobility. Hovering reveals the last recorded current and target statuses. Double-clicking opens an editor for quickly changing status. 

The same tools can be accessed from transition planning reports using interactive charting. A flow icon can be selected to review trends in patient SHS.

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. 

Frailty Informed Care

Frailty is a state of reduced function and health which increases the risk of immobility, falls, incontinence, cognitive impairment, malnutrition, depression, and social isolation. It represents an accumulation of deficits that result in loss of function across multiple body systems, which leaves a person more vulnerable to new stressors.

Frailty awareness can facilitate recognition of and attention to patients' mobility and other support needs during encounters, while improving planning for effective transitions between encounters.

Key resources explain how to use information tools and workflows in support of frailty-informed care:

Clinical Frailty Scale

The Clinical Frailty Scale (CFS) is a single-value metric that uses images to help clinicians remember which level of baseline (convalescent) frailty might apply to a particular patient. Use of the CFS can increase awareness of a patient's resilience and their prospect for timely recovery without additional (e.g., physiotherapy, occupational therapy) supports. 

Most Connect Care transition planning tools contain a link for viewing, entering and editing patients' Clinical Frailty Scale (CFS) scores.

Frailty Screening in Connect Care

Multidisciplinary team members (prescribers and non-prescribers) are encouraged to assign a baseline (convalescent or best function prior to any intercurrent illness triggering admission) CFS score as soon as possible (within 72 hours of admission) for inpatients aged 65 and older or for any patient with functional deficits or frailty syndromes. The initial assessment can be revised as more information becomes available during the inpatient encounter. 

Frailty Actions

Patients with frailty do better with early multidisciplinary engagement (e.g., physiotherapy, occupational therapy, social work, transition coordinator consults), allocation of appropriate patient support resources, and possibly geriatric medicine consultation.

Edmonton Frail Scale

Patients with mild to moderate frailty scores may merit more detailed assessment with the Edmonton Frail Scale (acute care and community care variants available in Connect Care). 

Frailty Order Set

Any patient with frailty (CFS 4+) could benefit from prescriber use of the "Frailty Adult" order set, available within inpatient encounters. This facilitates appropriate assessment, testing, intervention and consultation for patients screening positive for frailty.

Feedback Meaningful Use Metric

Feedback about trends in compliance with Frailty screening recommendations is addressed in Connect Care Meaningful Use Norms and the associated Meaningful Use Dashboard. 

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.

Primary Care Provider (PCP) or Service Attachment

Effective transitions from inpatient to community care are contingent upon availability of primary care provider(s) to monitor progress, coordinate care and facilitate post-discharge decision-making. However, many patients do not have a primary care provider, or reliable access to a consistent primary care service (e.g., primary care network, walk-in clinic, etc.).

Connect Care provides a number of visual cues to highlight a patient's primary care attachment(s):

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