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Discharge Planning Process (2.1.25)

Discharge Planning Process (2.1.25) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer


Policy Title: Discharge Planning Process
Policy Number: 2.1.25
Category: UW Health
Type: Inpatient
Effective Date: May 26, 2017


To provide a systematic means for achieving continuity of care for patients being transitioned from a UW
Health setting to another level of care.


Continuity of care is the process by which the patient is transitioned from one level of care to another in a
safe, coordinated manner. Coordination of care requires transmission of information needed for continuation
of a comprehensive plan to address the patient’s health. Discharge planning is one of the means by which
continuity of care for the patient and family is realized. Every patient, family or authorized representative has
the right to participate in a safe and coordinated discharge plan.

The primary responsibility for discharge planning rests with the attending physician and the primary nurse, in
collaboration with the patient, nurse case manager and other staff members as dictated by the individual
patient's needs. The case management team is comprised of the nurse case manager, social worker and
the Coordinated Care Resource Center staff. Discharge planning is initiated at admission or preadmission
when possible and may include referrals at any time during the hospital stay. Each patient receives a
discharge planning evaluation and post-acute referrals may be initiated by any staff member, the patient,
family members, or outside agencies. The goal is to assure that each patient is provided the services
required to maximize their health status, regardless of their post-acute placement.


A. Development of the discharge plan is an ongoing interdisciplinary process that includes the patient, family
and/or any authorized representative.
B. A screening admission assessment of the physical and behavioral health needs, and spiritual, social and
economic needs of the patient begins upon admission or pre-admission when possible. The attending
physician and primary nurse are responsible for the screening assessment and development of the
discharge plan collaboratively with the patient and/or authorized representative along with the input of the
nurse case manager. The nurse case manager is accountable for ensuring that each patient receives an
initial case management assessment within 72 hours of admission.
C. The nurse case manager is accountable to ensure a discharge planning evaluation is completed for each
patient and to delegate aspects of the discharge planning process to other team members as needed. The
discharge planning evaluation includes a patient’s capacity for self-care or the possibility of being cared for
in the same environment from which he/she entered the hospital. This evaluation also includes the likelihood
of a patient needing post-acute hospital services and of the availability of those services.
D. Discharge planning interventions are documented in Health Link.
E. Communication, coordination and ongoing monitoring of the patient's discharge plan occurs during daily
interdisciplinary rounds. Progress towards expected outcomes and barriers to discharge are assessed and
communicated to the interdisciplinary team.
F. Patient/family members are helped to evaluate choices available to them regarding follow up services. Both
the presentation of alternatives as well as the patient/family decision will be documented in Health Link.
G. Evaluation of the discharge planning process will occur on an ongoing basis, be communicated to the
interdisciplinary team and be documented in Health Link. The attending physician and primary/team nurse
are responsible for reassessing the discharge plan on day of discharge to ensure the appropriateness of the
plan. The discharge status board will be utilized as a real-time visual display of the patient’s discharge
process allowing staff members to plan and prioritize work for a timely and successful discharge.
H. Written referral information will accompany any patient discharged to another health care facility or agency.
(See Nursing Patient Care policy #14.19, Preparing a Continuity of Care Referral.)


A. The discharge plan will be developed by the patient's physician along with the primary nurse in collaboration

Policy Title: Discharge Planning Process
Policy Number: 2.1.25

with the patient/family, along with the input from the nurse case manager, social worker and other members
of the interdisciplinary team.
i. The plan will be based on the assessment of the physical and behavioral health needs, and
spiritual, social and economic needs of the patient. The areas assessed may include functional
ability, ability to perform self-cares, mental status, understanding and adjustment to illness, coping
strategies, patient/family strengths, support systems and financial resources.
ii. Based on patient assessment, the primary nurse and/or nurse case manager/social worker will
utilize and refer to hospital-based transitional care, complex case management and other home-
based services, as well as outside community resources to contribute to the discharge plan.
iii. The primary nurse and/or nurse case manager or designee will obtain consent of patient/family to
contact outside resources and document this in Health Link.
iv. The nurse case manager, social worker or designee will present post acute care options to the
patient/family. Both the presentation of options as well as the patient/family decision will be verbally
communicated with the interdisciplinary team and documented in Health Link.
v. Postacute discharge referrals will be based on patient choice to the extent possible. We are
obligated to inform the patient that UW Health has a financial interest in the referral to Chartwell
Midwest Wisconsin or UW Health Home Health Agency. This patient notification is documented in
Health Link.
vi. The nurse case manager may delegate some activities/tasks of the discharge plan to a clinical
nurse, social worker or the Coordinated Care Resource Center.
vii. Members of the case management team will collaborate with insurance utilization management
staff to determine insurance and managed care requirements and obtain necessary authorization
as required.
viii. For patients transferred to post-acute facilities (SNF’s, Assisted Living, LTACH) or referred to
community-based agencies, the nurse case manager, social worker, or designee will consult with
professional staff of the receiving facility to ensure that patient discharge needs can be met by the
receiving facility.
ix. The nurse case manager or designee will ensure that a primary physician will assume responsibility
for the care of the patient at the post discharge facility.
x. The physician, primary nurse or nurse case manager will identify patient needs requiring follow-up
in UW Health clinics and will communicate and coordinate care with appropriate clinic resources,
which may include the primary physician and clinic primary nurse.
xi. The nurse case manager, social worker or designee will update the discharge plan on an ongoing
basis, identify and document estimated date of discharge as well as potential barriers that may
hinder timely discharge. Entries will be made by all disciplines directly involved in developing,
implementing and evaluating the discharge plan. The plan is reassessed on an ongoing basis and
at the time of discharge to ensure appropriateness.
xii. The nurse case manager, social worker or designee will monitor final arrangements with the other
members of the interdisciplinary team as needed.
xiii. As part of the discharge planning process, the primary nurse or designee will validate accuracy and
completeness of the discharge orders and do a handoff phone conversation by providing an
updated nursing assessment and nursing report to the patient’s post-acute provider. These
providers may include nursing homes or other care options, such as LTACH's (Long Term Acute
Care Hospital), acute care hospitals, acute rehabilitation facilities, adult day care centers,
community options programs, assisted living facility, CBRF's (community-based residential facility),
etc.. The nurse case manager, social worker or Resource Center staff will complete the Health Link
Discharge Plan to ensure the health unit coordinator faxes a discharge packet to the appropriate
post-acute provider. In addition, the nurse case manager, social worker or Resource Center will
document the facility name and location in the Care Team section of Health Link. Any Health Link
facility database updates or corrections should be forwarded to the Coordinated Care End-User
Support Specialist.
xiv. When circumstances don't allow for a nurse case manager to assess and coordinate the patient's
care (patient has a less than 24 hr.. stay, patient admitted and discharged on the weekend or nurse
case manager unavailable), the nurse providing care is accountable for the assessment, plan,
intervention and evaluation of the discharge plan. On the day of discharge the physician and nurse
are accountable to assure that an appropriate discharge plan is in place. Referral to the social
worker or nurse case manager once the patient has been discharged is required if there are any
concerns or follow-up needs. The social worker or the nurse case manager will then contact the

Policy Title: Discharge Planning Process
Policy Number: 2.1.25

patient/family to address any questions or needs.
B. The physician, primary nurse, and nurse case manager will collaborate on needed referrals for continuing
care based on input from the interdisciplinary team. A referral recommendation can be made to the nurse
case manager by anyone identifying a specific patient/family need for continuing care upon discharge from
the hospital or while receiving care in the ambulatory setting.
C. The patient/family participates in formulating the discharge plan and is informed of the recommendation for
continuing care by the physician, primary nurse or nurse case manager. Consent of the patient/family is
documented in Health Link. An order is entered in Health Link for the post-acute services by the physician.
The attending physician or designee will inform the patient's referring physician of additional referrals when
communicating with him/her about the patient's discharge.
D. The interdisciplinary team of care providers participates in the discharge planning process as noted below:
i. Social Work:
a. As a member of the Case Management team, the inpatient social worker will work with the
nurse case manager to provide discharge services, especially in the areas of: financial
need, community or agency placement, determination of capacity, family/patient disputed
placement or complexity of patient care and needs. When a social worker is consulted,
ongoing documentation of discharge activities will be documented in Health Link.
b. The social worker will initiate and coordinate any legal requirements that impact care,
such as health-care power of attorney, guardianship, protective placement, etc.
c. The social worker collaborates with the nurse case manager and interdisciplinary team to
plan and implement transfers to nursing home or other care options such as LTACH's,
acute care hospitals, acute rehabilitation facilities, adult day care centers, community
options programs, assisted living, hospice, CBRF's, etc.
d. The social worker will provide psychosocial assessments and support to patients and
families as referred or identified by any member of the interdisciplinary team.
e. The social worker is available to assess and arrange for patient discharge transportation
when needed.
ii. Coordinated Care Resource Center:
a. The Coordinated Care Resource Center will assist the nurse case manager and social
worker by completing delegated aspects of discharge planning including:
1. Determining preferred providers.
2. Arranging for delivery of durable medical equipment (DME) and supplies.
3. Arranging discharge transportation.
4. Identifying agency and community resources and sending initial referral
5. Arranging for primary care follow-up or clinic appointments.
iii. Occupational, Physical and Speech Therapy, upon physician referral, are responsible to consult
and determine a plan of care that may include evaluation, treatment, recommendations,
determination of the patient's therapy discharge needs, patient and/or family education, and
contributions to the patient’s discharge plan. This may include documented recommendations
a. Recommend durable medical equipment (DME).
b. Recommended follow-up therapy services after discharge.
c. Recommended discharge placement setting.
d. Patient and family education performed to facilitate safe functional performance after
e. Patient’s consent to contact follow-up therapy providers/and or families informing them of
follow-up treatment and DME recommendations.
f. Therapy personnel may also assist with coordinating the arrangements for the patient to
obtain necessary durable medical equipment (assistive device, wheelchair, walker,
commode, bath bench, etc.).
iv. Pharmacy is responsible for:
a. Reviewing discharge medication orders for appropriateness and completeness versus the
patient's pre-admission medication history and inpatient medication regimen, and
reconciling differences with the prescriber.
b. Discussing medication needs with the patient, reconciling insurance and formulary issues
and confirming patient's pharmacy of choice and that the patient has an adequate means
for filling discharge prescriptions.

Policy Title: Discharge Planning Process
Policy Number: 2.1.25

c. Facilitating discharge prescriptions to the appropriate pharmacy as needed.
d. Reviewing patient payment mechanisms and communicating with medication access
specialists, social workers and case managers when an adequate payment mechanism
for discharge medications does not exist.

e. Discharge medication teaching to patient and/or appropriate individuals and providing the
patient with a printed list of medications the patient is to take upon discharge, written
educational materials such as drug monographs and Health Facts For You as appropriate;
and documentation of this teaching in Health Link.
f. Generating self-administration medication compliance aids for patient use post-discharge,
and reviewing these with the patient.
v. Respiratory Therapy Discharge Planning
a. The Respiratory therapy discharge planner reviews the patient record to determine health
status and potential respiratory interventions needed for discharge.
b. The Respiratory therapy discharge planner will provide clinical consultation to physicians
and UW Health System staff on respiratory therapy interventions and treatments for
discharge. This may include documented recommendations regarding:
1. Recommended respiratory DME
2. Recommended inpatient testing for qualification of respiratory DME
3. Recommended follow-up testing for qualification of respiratory DME
4. Recommended discharge placement setting based on respiratory status
c. The Respiratory therapy discharge planner will provide patient and family education and
counseling about existing health problems and related respiratory therapies/equipment.
E. All providers should be encouraged to enter discharge orders as quickly as reasonably possible. All
physician orders related to discharge must be entered in Health Link.
F. Unit Nursing Personnel are responsible to:
i. Review Discharge Orders for accuracy and completeness.
ii. Reassess the patient on day of discharge to determine that the discharge plan remains
iii. Ensure that anticipated/confirmed discharge dates and times are entered into Health Link
iv. Using teach-back method, complete all patient education needed prior to discharge with
documentation in Health Link.
v. Ensure the final Discharge Orders and After Hospital Care Plan (AHCP) presented to the patient
and/or family is complete and matches what is retained in Health Link (i.e., no handwritten
information on the AHCP).
vi. Follow-up appointments
a. The Health Unit Coordinator or nursing staff calls to coordinate any UW Health clinic
appointments with the appropriate clinic(s) and provides the patient with time, date, and
directions to the clinic. This information should also be added to the AHCP in the
appropriate appointment section.
b. Patients with a UW Health primary care provider who are being discharged to a skilled
nursing facility (SNF) in Dane County do not need to have a primary care post-discharge
follow up appointment scheduled as all Dane County SNFs are staffed with UW Health
advanced practice providers. All specialty and non-UW follow-up visits should be
scheduled as needed.
c. The Institute for Healthcare Improvement (IHI) recommends that follow-up appointments
are scheduled based on patient risk factors for readmissions. (See related documents
Scheduling Post-Discharge Follow Up Appointment (MDs) and Post-Discharge Clinic
Appointments (HUCs).
vii. Print and review the final AHCP with the patient/family.
viii. When patients receive continuing services (such as home health or a skilled nursing facility) ensure
the Release of Information (ROI) Inpatient Discharge Packet generated from Health Link is faxed to
the appropriate agency or facility as directed by the Health Link Discharge Plan. The HUC or RN
will file a Quick Disclosure in the patient’s chart to document the release of patient information.
ix. When patients receive continuing services, telephone the agency or facility and provide a current
update of the patient's condition at the time of discharge.
x. For any patient going to a facility, complete the “Facility Report” Part 1 and Part 2 in Health Link.
xi. Remove the patient’s hospital wristband.

Policy Title: Discharge Planning Process
Policy Number: 2.1.25

xii. At the time of the patient’s discharge, complete the final discharge in the computer in Unit Manager.
G. If a discharge is due to death, Admissions staff will notify the Information desk and all inquiries received
within hours will be directed to the nursing unit. The Information Desk staff notifies the nursing unit that
visitors are on their way to the unit.
H. Guidelines for referrals:
i. The completed referral paperwork for home care includes:
a. The ROI Inpatient Discharge Packet.
b. Reports from other departments where applicable.
c. A copy of the patient’s completed Advance Directive.
ii. Ambulatory clinic referrals:
a. A phone call is made to the clinic/agency if clarifying information is needed.
iii. The completed referral paperwork for facilities and institutions other than home care includes:
a. ROI Inpatient Discharge Packet which includes the signed SNF Discharge Order Set..
b. Physician Dictated Discharge Summary – signed if not contained in the ROI Inpatient
Discharge Packet.
c. Chest x-ray report current within 90 days if not contained in the ROI Inpatient Discharge
Packet. (Nursing Home placement only).
d. Reports from other departments not contained in the ROI Inpatient Discharge Packet.
e. A copy of the patient’s completed Advance Directive.
f. A copy of the ROI Inpatient Discharge Packet is printed and given to transport personnel
on all ambulance discharges.
I. When changes in the patient's discharge plan occur, a telephone call to the nursing home or agency will be
made by the nurse, nurse case manager or social worker caring for the patient.
J. Ongoing evaluation of the discharge planning process:
i. On a quarterly basis, the Coordinated Care Department will conduct an in-depth review of at least
10% of potentially preventable readmissions to determine if there was an appropriate discharge
planning evaluation and discharge plan that had been completed. A summary report of the results
is prepared and shared with Coordinated Care staff along with both medical and hospital
K. In unusual circumstances, such as discharge against medical advice or the patient/representative's refusal
to cooperate with discharge arrangements, some of the requirements of this policy may not be applicable.


Author: Director, Coordinated Care and Case Management
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: none
Approval committees: UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: February 20, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee


Scheduling Post-Discharge Follow Up Appointments (MDs) (in related tab of this policy on U-Connect)
Post-Discharge Clinic Appointments (HUCs) (in related tab of this policy on U-Connect)

Policy Title: Discharge Planning Process
Policy Number: 2.1.25

The Joint Commission -Accreditation Manual for Hospitals
Nursing Patient Care policy #14.19, Preparing a Continuity of Care Referral for an Inpatient Discharge (Adult
and Pediatric)
Pharmacy departmental policy #3.1, Pharmacist Discharge Reconciliation and Order Modification
UW Health administrative policy #13.04, Communicable Disease Reporting

Version: Revision
Last Full Review: May 26, 2017
Next Revision Due: May 2020
Formerly Known as: Hospital administrative policy #7.15