1. A Holistic Approach To Discharge Planning

2. Due to the regulatory guidelines and changes in healthcare for example: Bounce backs Reduced hospitalizations Striving for excellence our Interdisciplinary Team through a collaborative effort identified the key areas for a successful discharge Catalyst for Change

3. This process was initiated by intense research on the most common disease entities Through this we identified the most direct information in order to facilitate patient/family education Through careful consideration an enthusiastic nurse educator was designated to initiate the education process The primary nurses continue with ongoing education and documentation Implementing Change

4. Measuring Success Interdisciplinary meetings held daily to discuss patient progress Daily communication with primary nurse, patient, family, physician, and case manager Goals are modified as needed Care Planning meeting to evaluate patient readiness to transition home by Educational outcome Review of rehab goals Home care needs ID of key community support

5. Key Areas 1.Discharge planning begins on admission 2.After a review of the record and patient assessment, the Interdisciplinary Team collaboratively establishes realistic patient specific goals 3.Meeting with patient/family to identify key community supports, social situation, and patient specific measurable goals to facilitate within 72 hours 4.Educational needs of patient and family are reviewed, condensed, communicated, and initiated

6. Optimal Discharge Contact with community agency for real-time handover communication Case manager facilitates discharge process through the Interdisciplinary Team and patient/family support Communication with previous healthcare providers Primary MD to schedule follow-up appointments Specialists – follow-up appointments VNA Other supports – ASAPS Private help