Patient Discharge Planning: A Change Proposal

Subject: Nursing
Pages: 9
Words: 2501
Reading time:
9 min
Study level: College


Medical mistakes, unfavorable occurrences, and poor patient healthcare outcomes might result from inadequate transition planning. Hospitals may incur annual costs of $12 billion to $44 billion due to these problems. Care management databases that care transfers from hospitals to homes, nursing homes, or post-acute care facilities must be effective. Compensation costs created by the Institutions for Medicare and Medicaid Facilities, private coverage companies, and governing organizations encourage and incentivize healthcare organizations to improve care transitions. Programs that promoted cooperation by providing bundled payments or shared savings were also created due to these incentives. Current best practices for discharge planning encourage procedures that prevent and steer clear of barriers to appropriate transitional care. This strategy assessment of the discharge scheduling procedure was based on an analysis of the available data.

A thorough literature review on care transitions and discharge planning was conducted. The literature’s common themes led to the discovery of best practice suggestions. Discharge planning best practice suggestions was compared to an analysis of the policies and practices of three healthcare institutions in Southern California. The project’s main emphasis was on communication within each organization and risk-assessment tools concerning various care transitions of care kinds and places. These care transition choices included acute rehabilitation, skilled nursing facilities, and home health. With measures to overcome insufficient changes of care difficulties, possible discharge barriers were identified, and facility transfers were secured.

Clinical Problem Statement

This essay addresses the issue of discharge planning, patients’ medical insurance, and internal and external medical team involvement, particularly when moving from an acute-level institution to a higher one. It also focuses on determining how nurses’ contributions to discharge planning affect patient outcomes. It strives to develop procedures and tactics that prevent delays in discharge planning-related issues. Nurses must consider educating patients about the numerous difficulties before releasing them. The nurses should continually evaluate a patient’s level of comprehension before release. To ensure there is sufficient comprehension, they might use several techniques. For instance, to make sure they understood, they may ask the patient who was being discharged to repeat the instructions. Following discharge, patients should be given important health messages, such as medication adherence and frequency. To enable acute families or patients to communicate a necessary degree of understanding of their condition and treatment upon release, nurses should concentrate on developing a standardized discharge checklist.

Purpose of the Change Proposal Concerning Providing Patient Care in the Changing Health Care System

Discharge planning continues to be plagued by poor communication and pointless delays. Delays can result in adverse health outcomes, which substantially impact older people with various acute and chronic diseases. This may result in a more extended hospital stay and the requirement for long-term care. The critical care patient group, particularly the older adult demographic, was the target audience for this initiative. There were two objectives or goals for this policy review. First, a literature review revealed recurring patterns in the best practices targeted at the inpatient hospital discharge planning procedure.

The discharge planning policies and procedures for three distinct healthcare organizations were then reviewed, along with their respective communications and transitions of care domains. To assess each organization’s policies, communication methods, and tools, the hospital’s present discharge planning policies and tools were compared to the best practice themes the evidence had found. The discrepancies between the existing documentation identified areas that needed more attention to highlighting potential barriers within the organization’s range of care changeovers and suggested possible policy reform.

PICOT Question

According to the PICO pneumonic;

  • P: Acute care families/patients ready for release,
  • I: To avoid delays while releasing patients, create a consistent discharge checklist.
  • C: The nurse’s current protocol for giving instructions to avoid discharge delays
  • O: Upon being discharged to the next level, the patient verbalizes a sufficient degree of disease/treatment comprehension.

Nurses are the independent variables in the PICO question because they are crucial to guarantee patient satisfaction. The patient’s comprehension and contentment are the dependent variables. Patients who are discharged from care institutions make up the population. The clinical issue that frequently directs the pursuit for qualitative papers is: Will developing consistent discharge specifications assist acute maintenance patients in expressing an appropriate degree of comprehension of their action upon release to the next facility?

Literature Review

The Chamberlain College of Nurturing Library’s folder was used for the search. The PubMed Wellbeing database was used. The keywords “nursing” into Google, and 58,402 articles about nursing appeared. Next, “discharge planning” was typed, which showed a decrease to 20,372 pieces (Meo et al., 2020). Release planning and patient degree of comprehension of disease/treatment following discharge was the refinement I needed to input to find pertinent publications. Two hundred articles were given to the two relevant articles that will be used to provide direction for group projects and the following paper. Support for families of people with schizophrenia in Asian Americans: a psych educational and Purdy. Planning for NICU release and beyond: suggestions for parent psychological assistance. The two papers were picked because they feature material from recent publications and their publication dates are less than five years apart. The author’s knowledge was superior to that of all the other papers that were not selected. The articles may aid in the illustration of all the facts that needed more for subsequent work because the articles’ main topic was discharge planning.

Furthermore, The Collective Index of Treatment and Allied Health Works, ProQuest, and PubMed were also databases used. Patient Discharge, Training Guidelines, and Nurturing were the primary search keywords utilized throughout all queries since they were MeSH (Medical Subject Headings) for the PubMed exploration. When used interchangeably, the phrases “Communication tools,” “Case Management and “Handoff” yielded minimal to no effects. The essential phrases were repeated in the other two database searches to maintain uniformity. With all databases, the standard Boolean operation AND was applied. The following search criteria were standard across all folders: “English,” “full text,” and “periodical era within ten years.” Twenty-one articles were found in PubMed as a result of this search. The CINAHL database yielded 176 articles using the same search parameters. Eight academic publications were left after restrictions on just “USA” articles and age ranges for “adults.”

In this database, 26 articles were found. Fifty-three items were created from all databases, and two duplicates were removed. Articles with pediatric patients were omitted when the final search results were examined. This was crucial to ensure that the intended demography of the intervention was considered while evaluating the evidence. Forty-four were further excluded after the pediatric population literature was removed, and a comprehensive text evaluation was done to ensure relevance to optimal practice. As a result, nine items from this literature database search were evaluated. In order to find state and state supervisory procedures pertinent to discharge scheduling, a different computerized search was conducted. This investigation led to the discovery of five sources altogether. Three of the national regulatory agencies used were the Institutions for Medicare & Medicaid Processes, the Joint Commission (JC) for health centers accreditation requirements, and the Organization for Healthcare Investigation and Quality. These organizations’ policies and standards were obtained and evaluated. From this search, two more sites that are pertinent to discharge arrangement standards and best perform have also been added. When the literary and electronic searches were merged, 14 sources were found that might be used to provide discharge planning recommendations for best practices.

A project’s development requires a literature evaluation, especially when dealing with a medical profession like nursing. The researcher has a better comprehension and a more comprehensive perspective after considering the most recent pieces of evidence, components, concepts, and theories on the subject of the investigation. It is possible to improve the practice environment and patient outcomes by incorporating evidence-based practice (EBP) into medical practitioners’ daily practices (Cleary-Holdforth et al., 2021). Nurses must become more knowledgeable, standardize their procedures, and improve patient outcomes. Therefore, nurses should base their clinical judgments on the best and most current research data readily available. This essay aims to evaluate how EBP affects nursing care and patient outcomes linked to discharge planning. It will also help us understand how nurses’ sense of accomplishment motivates them to provide better patient care. This will be accomplished by contrasting the research goals, sample demographics, and limitations of the studies evaluated in the literature.

Evaluation of the literature

Following the in-service, a survey was delivered to the rehabilitation therapists as part of the project assessment procedure. The capstone student’s professor, adviser, and site mentor looked over the survey for measurement issues. Five questions were used on a Likert scale to determine how the therapist experienced using the project materials. There was also a free-response section for more comments. Twelve of the N=16 members said they were likely to utilize the normal checklist, while four said there was a high probability that they will use it. Seven people said they would likely write routines on patients’ whiteboards, while nine said they would very likely do so.

Four and twelve participants both highly agreed that the discharge goals checklist would benefit interdisciplinary discussions. Nine people agreed, one disagreed, and six members approved that the rehab chart will assist direct their strategy. Finally, eight participants firmly concurred that they grasped the rationale behind each stage in the rehab flow chart. Following project completion, informal interactions with stakeholders served as another type of project evaluation. After the in-service, many therapists discussed the capstone project, asking questions and identifying areas that may be improved. The capstone student noted these inquiries and recommendations and then collected them into a summary of their opinions on the undertaking. The capstone mentor was told about this. Input from the case manager and nurse administration was also helpful in the assessment process. The occasion manager said she will likely continue to be interested in this project.

Applicable Change or Nursing Theory Utilized

The self-care theory, which is based on Orem’s medicine theory, is the nursing theory that was used in this study. This approach strongly emphasizes people’s inherent ability to care for them (Khademian et al., 2020, p. 141). These views contend that nurses should consider patients as capable individuals who can make decisions about their health in addition to the treatment received at the health center rather than as passive recipients of services intended to enhance their health. This initiative concentrates on utilizing education to encourage change to lower the EBP associated with the patient’s discharge plans, resulting in a resource load on the hospital.

Proposed Implementation Plan with Outcome Measures

The planned intervention will take several measures to ensure that patient education is successful for all patients. As soon as a patient is admitted, education will start for them. As a result, the nurses will be able to connect well with the patient’s rights immediately. Then, nurses will try to find out what the patient knows about their illnesses and dispel any misunderstandings they might have. Nurses will explain the information on treating their diabetic condition in simplified words by correctly utilizing the available visual aids. During sessions, nurses will also inquire about the patient’s understanding of care concepts and make plans for the subsequent session. Nurses will employ technologies like mobile portable devices to educate patients. The patient’s excellent comprehension of the discharge plans was the outcome. The critical factor is the patient’s demonstrable mastery of the discharge preparation.

Discussion of how Evidence-Based Practice Was Used In Creating the Intervention Plan

A suitable intervention strategy demonstrated to work was developed using evidence-based practice. It was determined that the best course of action was to use patient education, which has been demonstrated to be effective via study. When there are adequate resources, such as nurses, time, and equipment, patient education is offered, according to research by Fereidouni et al. (2019). Because of this, the intervention strategy includes these elements to guarantee that the stakeholders get outstanding results. When the conditions are right, EBP notes that nurses educate patients properly.

Plan for Evaluating the Proposed Nursing Intervention

The summative assessment approach will be used to assess the outcomes. Using this strategy, the researcher can gather the data required to assess if the predicted results were realized. One of the project’s main goals is to address the issue of discharged patients’ understanding of the discharge plan to improve their experience after discharge. To determine if this result was realized following the implementation of the education program, the number of readmissions in the hospital following release will be gathered. The review will also identify the primary reasons for readmissions. To ascertain if a change is successful, nurses must offer feedback on patient interactions.

Assessing this policy, checklist for evaluating policies will also be developed predicated on the general themes identified in the data and in accordance with the National Accreditation board guidelines and CMS recommendations. Guidelines from three healthcare centers in Northern Florida were obtained and analyzed with the approval of the case participative administration for each organization. With two facilities and 808 medical beds altogether, Group A is a Level I trauma, burns, and stroke institution recognized by the National Malignancy Institute. Allied medical facility Organization B offers a Level I and Level II juvenile burns and trauma facility in addition to 417 acute treatment beds. Veterans are served by Organization C, a healthcare facility with 304 beds that the federal government supports—finding policy details and keeping the project on schedule required adjustments based on each organization’s ability to provide case management leadership. Multiple correspondences were held during the practicum since none of the criterion’s supporting documents could be found in one policy.

Identification of Potential Barriers to Plan Implementation, And a Discussion Of How These Could Be Overcome

Lack of funding from stakeholders is the primary potential obstacle anticipated. These include nurses who will be primarily responsible for nursing education. Discussion forums will be used to address this issue to drive home how crucial the change is. Accessing the appropriate technology to assist the project will be another difficulty. The project’s viability and ability to enhance patient outcomes concerning discharge planning will be shown to the hospital board and medical partners.


Patient satisfaction rates at the hospital increase due to the adoption of EBP training for nurses. A six-hour intervention program should lead to a greater sense of personal success, lower rates of burnout, and better health care services since the training improve both emotional state and professional competence. Since nurses use the latest scientific information to care for and treat both people and communities, EBP improves patient care. Additionally, EBP uses data related to a patient’s condition so that nurses may choose the best course of action, improving the recovery rate. The research has yet to demonstrate how EBP has contributed to greater satisfaction because all eight publications have only focused on the amount and depth of EBP training, attitudes, beliefs, and knowledge. This study should focus on how EBP affects patient care and nurses’ professional competency. It should cover how nurses’ feelings of accomplishment motivate them to provide improved patient care.


Fereidouni, Z., Sabet Sarvestani, R., Hariri, G., Kuhpaye, S. A., Amirkhani, M., & Kalyani, M. N. (2019). Moving into action: The master key to patient education. Journal of Nursing Research, 27(1), e6.

Khademian, Z., Ara, F. K., & Gholamzadeh, S. (2020). The Effect of Self-Care Education Based on Orem’s Nursing Theory on Quality of Life and Self-Efficacy in Patients with Hypertension: A Quasi-Experimental Study. International Journal Community Based Nursing Midwifery, 8(2), 140-149.

Meo, N., Liao, J. M., & Reddy, A. (2020). Hospitalized After Medical Readiness for Discharge: A Multidisciplinary Quality Improvement Initiative to Identify Discharge Barriers in General Medicine Patients., 35(1), 23–28.