Clinic’s Early Screen for Discharge Planning Tool

Healthcare specialists have a huge variety of tasks, including evaluating patients’ conditions, monitoring treatment outcomes, and helping clients deal with their health issues. However, to guarantee further improvement in patients’ health and facilitate home health agencies’ work, thorough planning after a hospital discharge is required.

Problem Statement

The absence of clear guidelines for patient discharge caused by the lack of a proper leadership strategy and the lack of coherence in organizational management affects the quality of healthcare services at NurseCore.

KPI and Outcome Measures

The proper performance of specialists working for different home health agencies is related to the accuracy of the discharge planning process. The problem of poor patient discharge planning is widely discussed today. Many hospitals develop and implement particular strategies and tools helping to evaluate and address the risks of readmissions and exclude the presence of broken or ineffective post-discharge plans (Pellett, 2016; Socwell et al., 2018). According to Socwell et al. (2018), a large number of preventable hospital readmissions result from a lack of effective communication between hospital teams and carers after discharge. Numerous hospital discharge policies used today are based on the assumption that the success of the interprofessional collaboration is predictive of long-term health outcomes for patients (Goldman et al., 2016; Vyt, 2017). Thus, the quality of collaboration between different specialists can help measure the project’s success.

The outcomes of poor discharge planning are usually discussed concerning hospitals’ performance and readmission rates, but some studies are analyzing the issue from the viewpoint of home health agencies. According to the state-wide survey of home health specialists, more than half of them report the low quality of information about patients and their support needs that they receive from other providers (Jones et al., 2019). As is stated by Jones et al. (2019), little is known about the ways to make patients more prepared to receive home health care, which involves the need for further research.

Project’s Value: Personal and Organizational Goals

It is believed that the project will have a profoundly positive effect on NurseCore’s performance, as well as on my professional growth. The information learned during the course will inform my development and the focus on building a multidisciplinary team in which key ethical principles such as benevolence and nonmaleficence, as well as the significance of Corporate Social Responsibility (CSR) and reciprocity in the patient-nurse dialogue, are upheld (Vyt, 2017). Furthermore, it is believed that the acquired knowledge will allow rearranging organizational resources in a way that will increase utility and reduce waste so that healthcare services could be of maximum efficiency.

In addition, the changes described above will produce a direct impact on the acquisition and use of leadership skills in the context of NurseCore. Given that the current strategic direction of the facility involves continuous improvement and the promotion of effective talent management, the integration of innovative leadership approaches will be especially useful (Goldman et al., 2016). Moreover, the application of the leadership styles and techniques, such as the transformational approach, to boost the levels of staff’s engagement, loyalty, and responsibility will produce a positive change.

The changes in organizational performance will also have to be supported by alterations in the organizational climate geared toward collaboration and effective management of workplace conflicts. Research states that cross-disciplinary collaboration, which is critical for providing high-quality healthcare services, is often interrupted by confrontations caused by the changing role of nurses in the clinical setting (Vyt, 2017). Therefore, shifts in the hierarchical perspective and disagreements in the workplace may lead to conflicts that have to be addressed and managed respectively (Jones et al., 2019). In turn, the project in question will allow one to create the corporate philosophy driven by the notion of mutual respect, cooperation, and communication.


Goldman, J., Reeves, S., Wu, R., Silver, I., MacMillan, K., & Kitto, S. (2016). A sociological exploration of the tensions related to interprofessional collaboration in acute-care discharge planning. Journal of Interprofessional Care, 30(2), 217-225. Web.

Jones, C. D., Jones, J., Bowles, K. H., Flynn, L., Masoudi, F. A., Coleman, E. A., … Boxer, R. S. (2019). Quality of hospital communication and patient preparation for home health care: Results from a statewide survey of home health care nurses and staff. Journal of the American Medical Directors Association, 20(4), 487-491. Web.

Pellett, C. (2016). Discharge planning: Best practice in transitions of care. British Journal of Community Nursing, 21(11), 542-548. Web.

Socwell, C. P., Bucci, L., Patchell, S., Kotowicz, E., Edbrooke, L., & Pope, R. (2018). Utility of Mayo Clinic’s early screen for discharge planning tool for predicting patient length of stay, discharge destination, and readmission risk in an inpatient oncology cohort. Supportive Care in Cancer, 26(11), 3843-3849. Web.

Vyt, A. (2017). Development and validation of a questionnaire to self-assess the quality of interprofessional team meetings in primary and community healthcare. Journal of Interprofessional Care, 31(2), 140-146. Web.