Patient Experience UDF/Nursing / MD Responsibilities Program changes Within 24h
of
Admission
• Patient understands the extent of the illness/injury • Patient understands clinical
targets for discharge • Patient understands
predicted length of stay and targeted discharge date.
• UDF contacts Senior Resident to discuss patient and plan of care and targets for discharge. • UDF meets with patient and
explains role and purpose of discharge rounds.
• UDF leaves business card with patient.
• UDF documents targets for discharge on the white board.
• UDF becomes the primary contact for the patient related to the discharge process • “Huddle Rounds” become “Discharge
Rounds” and are conducted at the bedside with the team (UDF, SW, MD if possible, OT/PT,FC)
• UDF contacts senior resident daily to discuss targets for discharge and the plan for the day if attending not present during “discharge rounds”
• UDF meets with patient within 24 hours of admission to review targets for discharge.
Inpatient stay
Patient aware of special needs, equipment, treatments and medications required for a safe discharge.
Bedside RN begins preparations for impending discharge:
• Begin teaching patient/family on self care, wound
management, device care, medication administration • UDF writes plan for the day on
the white board daily.
“Discharge rounds” occur daily at the bedside and include patient and family.
Discussion items include: • plan for the day, • discharge targets,
• discharge location; home, SNF • financial issues
• discharge medications • co pays
2 Days Prior to Discharge
• Patient has had time to think about illness/injury and any concerns post discharge. • Patient can make
arrangements for
UDF begin discussions around: • Transportation home • Where to fill prescriptions
HMC/outside • Possible co pays
“Discharge rounds” discussion:
• specific concerns are discussed to prepare patient for discharge. • transportation home
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transportation home.
• Patient has time to ask family to bring in source of payment for prescriptions if filled at HMC.
• Bedside nurse to arrange rehab assessment if patient with complex injuries is going home. • UDF writes patient plan on the
white board.
medications filled
• is the patient aware of co-pays? Source of payment?
• Discuss need for rehab assessment for discharge transfer for complex situations in preparation for transfer into the car on the day of discharge.
Patient Experience UDF/Nursing / MD Responsibilities Program changes 1 Day before
of Discharge
• Patient feels confident that all members of the team relay the same information relating to the plan for discharge and follow-up care.
• Patient can plan for the time of discharge in terms of transportation and follow-up help at home if necessary. • Patient has opportunity to ask
questions related to self care, treatments or medications that must be followed at home.
• Patient identifies concerns surrounding discharge.
• UDF writes patient plan on the white board.
• UDF writes proposed DC times on the white board.
• Bedside nurse/UDF and physician round to clarify plan for discharge 24 hours in advance. Team is all on the same page.
• Patient informed of proposed time for discharge the next day. • Review plans for transportation
home, medications, supplies and any special needs.
• MD writes discharge orders if possible.
• UDF becomes responsible as the primary discharge resource. Reviews all information in the discharge packet with the patient. Reviews all of the plans for discharge.
Day of discharge
• Patient feels like staff has the time to discuss any concerns.
• MD writes discharge orders early to facilitate targeted
• UDF responsible for final discharge plan • UDF verifies prescriptions and supply needs.
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• Patient feels comfortable with self care, specialized
treatments and medication administration that must be followed at home.
• Patient understands plan for discharge
• Patient understands discharge instructions
• Patient understands plan for follow-up care.
discharge times.
• UDF rounds and explains discharge process to patient. • Patient informed of discharge
time.
• Interdisciplinary discharge form printed off and ready to sign. • Bedside nurse reviews
discharge medications with the patient for understanding. • UDF reviews the discharge checklist with the patient to identify areas that remain to be discussed with patient/family.
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Patient Experience UDF/Nursing / MD Responsibilities Program changes
Accompany Patient out of Hospital
• Patient feels prepared for discharge.
• Patient is confident that all discharge requirements are met.
• Patient leaves with all personal property.
• Patient appreciates meeting time frames as directed. • Patient is confident that they
will be safety transferred into the car.
• Escorted out of the hospital by hospital personnel.
• Stop by the discharge desk
• Stop by the pharmacy if meds need to be picked up.
• Assist patient into the car
• Bedside RN determines the level of assistance needed to get the patient into the ca safely.
Follow-up Post Discharge
• Patient feels cared for. • Patient has an opportunity to
ask questions or relay concerns.
• UDF makes follow up phone call to patient 1-2 days post discharge.
• UDF will now make the follow up discharge phone calls using a standard set of questions. • UDF will document in ORCA that the outcome
of the discharge phone call.
APPENDIX M – COMMITTEE REPORTING STRUCTURE