Comprehensive Discharge Planning
Gap Analysis of Best Practices/Strategies for Improvement
Component
Discharge
Planning Process
Best practice/Strategy
Conduct pre-discharge assessment
of ability of patient/family to provide
self-care (includes problem solving,
decision making, early symptom
recognition, and taking action,
quality of life, depression and other
cognitive and functional ability
factors)
Develop a comprehensive shared
care plan using a shared decision
making approach – consider patient
values and preferences, social and
medical needs
Discharge summary and medication
plan are complete and up to date
Work with patient/family to prepare
for the post discharge visit planning
(goals, questions, concerns)
Discharge
Planning –
Content
Work with patient/family to complete
advance directives as appropriate
Written discharge plan includes the
following:
 Reason for hospitalization
 Medications to be taken post
discharge, including, as
appropriate, resumption of preadmission medications.
 Self-care activities such as diet,
activity level or limitations,
weight monitoring
 DME/supplies that patient will
need for care
 Symptom recognition and
management – what to do if
patient has a question, a
problem arises or condition
changes, including of symptoms
of which to notify health care
provider
 Coordination and planning for
follow-up appointments
 Coordination for follow up of test
and studies for which confirmed
results are not available at the
time of discharge.
Present
Gap/Opportunity

Care
Coordination
Coordination of community
resources patient will utilize,
such as:
o Home Health Care
o Meals on Wheels
o Adult Day Care
o PT, OT, ST
The written discharge plan should
be easy to read:
 Include only essential education
on health condition
 Utilize plain language - clear,
straightforward expression,
using only as many words as
necessary
 Use universal principles of
health literacy to specify readerfriendly written materials: simple
words, large font, short
sentences, short paragraphs, no
medical jargon, headings and
bullets, highlighted or circled
key information, lots of white
space, use visual aides
Make appointments for follow-up
and post-discharge testing, with
input from the patient regarding time
and date
Use personal health records or
patient portals so patients have
access to necessary information
(lab results, radiology results,
request prescription refills, ability to
email doctors, nurses, and staff with
questions)
All care providers have a complete
discharge summary
All care providers know their care
roles and responsibilities
Conduct post discharge telephone
care management
Health Literacy/
PatientProvider
Communication
Educate the patient about diagnosis
throughout the care continuum
Embed health literacy principles into
all patient education and
interactions
Give the patient a complete and
written discharge plan
Employ teach back to ensure
patients/families understand the
care plan, information and
explanations given and that their
questions are answered
Provide culturally and linguistically
appropriate care
Ensure continuity in care in order to
build trust
Use a shared decision making
approach
Ensure enough time is available for
consultation
Discuss with the patient any tests or
studies that have been completed
and who will be responsible for
following up the results
Confirm the medication plan with
the patient
Ensure provider contact and followup information is provided to the
patient
Review with the patient appropriate
steps of what to do if a problem
arises
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