Module B: The Patient-Centered Discharge Plan

CE Credits: 2.25

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This module explores the best practices of discharge planning: making transitions as smooth as possible, and educating and empowering the patient in his or her own recovery. The module begins by detailing the components of a patient-centered plan—one in which the patient and his or her family play a part in discussing goals and expectations—and the necessary steps of implementing such a plan. Next, the module details the best practices in engaging with patients—such as determining health literacy, or offering culturally and linguistically appropriate service—and how to identify possible barriers to care.

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Learning objectives: After completing this module the case manager will be able to:
» Discuss patient-centered discharge planning
» Identify steps to implement a patient-centered discharge plan
» Discuss methods to effectively engage patients and caregivers
» Discuss complex cases and barriers-to-care in discharge planning

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Advance your professional practice:: Case managers play a critical role in a patient’s hospital stay—especially when we create the patient’s discharge plan. If we understand the components of an effective discharge plan, we can increase the odds that patients will have a good outcome in terms of recovery, and avoid either readmission or adverse drug events.

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Improve organizational performance: Well-executed discharge plans help prevent extended length of stays (LOS) and readmissions to the hospital. When all team members understand the elements of effective discharge planning, teams will have better communication and collaboration to successfully implement those discharge plans together.