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. They benefit from multidisciplinary planning to facilitate safe and timely transitions that reduce early re-admissions.
Transition Care (Discharge) Plan
Effective transition planning is facilitated by shared understanding of patients' needs. This includes consideration of a patient's health and social supports prior to admission, changes occurring during an admission, and how new needs will be addressed after discharge. Transition care plans are team plans. They leverage consensus-building among participating disciplines and clinicians.
Transition (Discharge) Planning Tools
Connect Care provides supports that can help build and revise transition plans. These serve complex discharges best, improving communication to those continuing care after discharge. A "transitions planning package" includes a core transition plan, plus tools that help multidisciplinary teams contribute to part or all of a plan. These include:
Admission and Discharge Navigators
Expected Discharge Date (EDD) editor
Medical Readiness Date editor
Discharge Disposition (expected destination type) editor
Safe Handling Status (e.g., 2-person assist for transfers/mobility) and Target editor
Frailty Assessments scale
Daily and Discharge Checklists
Rapid Rounds (Discharge Planning) Inpatient Lists
Discharge Planning Sidebars
Discharge Planning Documentation
Standardized Discharge and Transfer Summaries with LACE Index readmission risk awareness
Communications to Electronic Health Record (Netcare) and Electronic Medical Records (eDelivery)
Transition Planning Performance Metrics
Good transition planning aligns with meaningful use norms that apply to all prescribers.
This section defines Connect Care's transition planning tools, with links to more detailed sections, tips, guides and demonstrations.
Discharge Planning Sidebar
A Discharge Planning Sidebar can be opened in Patient Lists workspaces as well as within any chart opened to an inpatient encounter. The sidebar contains tools for direct editing (no need to open a chart if viewed in patient lists) of key transition plan elements.
The discharge planning sidebar eases management of the following plan elements:
Expected Discharge Date
An Expected Discharge Date (EDD) represents a rough estimate of when a patient will be ready for discharge, with key milestones complete and barriers resolved. The EDD can be entered from a variety of workflows, along with narrative observations about factors that might affect the EDD. EDD estimates are refined and revised throughout a hospital admission.
Medical Readiness for Discharge
When active medical issues have been addressed as far as possible at the current facility, the patient is considered "medically ready" for discharge. This means that, absent other needs like reactivation or destination facility acceptance, the patient could return to the community or to a needs-appropriate alternate healthcare facility.
Patients who are medically ready for transition to a different level of care should be considered for a change from "Acute" to an "Alternate Level of Care" (ALC) designation. This ALC status is normally initiated at the same time that a patient is marked "Medically Ready" for discharge.
Safe Handling Status and Target
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 six 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 in pop-up form from within transition planning reports, using interactive charting. A flowsheet icon can be selected to review trends in a patient's SHS.
Discharge Disposition (Destination)
Patients may return to some form of independent living (e.g., private residence) at discharge. However, many have needs that can only addressed by another healthcare facility. Different categories of facilities (e.g., continuing care, acute care, hospice, rehabilitation) have different functional and informational placement requirements that must be met before a patient is accepted. Accordingly, it is important to be aware of an expected discharge destination as soon as possible and to adjust transition preparations accordingly.
Discharge dispositions can be entered directly within the discharge planning sidebar. When displayed in transition plans, the expected discharge disposition is interactive. Clicking on the word(s) opens a pop-up editor for making quick changes to the disposition. Disposition editing tools include supports for specifying a specific destination facility, if known.
Discharge Milestones and Delays
As an EDD nears, inpatient care teams can increase the chance of a timely discharge if milestones (dependencies) and delays are exposed and managed. The discharge planning sidebar has a section where milestones are listed. Typically, these must be completed for discharge to proceed. Delays relate to factors, such as transport availability, that postpone discharge beyond the EDD despite all milestones having been met.
A milestones and delays pop-up editor can be activated by selecting interactive text within discharge plans.
Discharge Planning Reviewed
The section immediately below Milestones and Delays provides a button that can be selected to update the last timestamp for when discharge information has been reviewed. This applies to all considerations within the discharge planning sidebar, not just the Milestones and Delays.
Click the button to record a time and date of last team review (e.g., at Rapid Rounds) and note the display of this information.
Discharge Plan Interactive Synopsis
The bottom section of the discharge planning sidebar provides a text summary of discharge planning considerations, such as patient decision-making capacity, frailty, readmission risk and supports required pre-admission and post-discharge.
Discharge Planning Report
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:
Key patient and care team identifiers, responsible hospital service and primary provider team
Patient linguistic needs, goals of care, decision-making competency (and supports), MyChart status
Pre-admission community supports
Current support needs
Anticipated post-discharge destination and supports
Safe Handling Status and Discharge Target
The report is interactive. Most items can be selected (clicked on) to open relevant displays of more detailed information and/or editing tools. The same report can be viewed within the "Patient Journey" chart summary view and as a pop-up linked from within transition planning tools.
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 Multidisciplinary Planning Patient Lists
"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 - For use during multidisciplinary discharge planning rounds, for quick information access and documentation while reviewing a panel of inpatients.
Rapid Rounds Report - Provides a compressed summary of discharge planning information together with interactive tools for updating key data and multidisciplinary discharge readiness indicators.
Discharge Planning Sidebar - For use when a chart is opened to an inpatient encounter, replicating much of the information found in the Rapid Rounds report while speeding access to information best updated during day-to-day care.
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.
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).
Connect Care provides a number of visual cues to highlight a patient's primary care attachment(s):
Patient Lists
Transition Planning Tools
Chart Storyboard
Chart Sidebar
Summative Documentation Templates
Communications
After Visit Summary
Admission and Discharge Navigators
An Admission Navigator promotes sequential attention to what matters most for a safe entry to hospital. This includes information about a patient's frailty, pre-admission community and social supports (e.g., home care), all summarized in the "Transition Planning" section of the admission navigator. This information is interactive (click to edit) and flows through to discharge planning workflows.
The Discharge Navigator picks up discharge planning information revised throughout an admission, highlighting changes that have occurred in hospital and exposing new needs for communication to post-discharge care providers.
Admission, Daily and Discharge Checklists
Transition planning checklists appear in the default inpatient sidebar view that shows when any inpatient chart is opened. Three checklists group "admission", "daily" and "discharge" tasks. The same checklists can be accessed within patient lists (an available default report) and via a chart activity (menu search for "checklist").
Checklists improve awareness of things like discharge date and readiness documentation requirements, as well as specific actions that should be considered prior to discharge.
Documenting Transition Plans
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.
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.