Actual and potential discharge planning needs of the patient/family will be assessed on the basis of the following criteria:

• the level at which the patient and family or other caregiver understands the patient’s medical condition and the reason for hospitalization.
• the patient’s stated expectations.
• tasks the patient can/cannot accomplish as a result of their current health problems.
• socio-cultural and religious practices and beliefs.
• age-related issues.
• language and language barriers.
• physical and/or cognitive limitations.
• desire and motivation to learn.
• emotional and mental status.
• financial resources available to assist with discharge needs.
• social support systems available to assist patient/family/other caregiver.
• level of post-hospital care needs (e.g., acute, intermediate, long term).
• nature and complexity of post-hospital care needs (e.g., patient safety, infection control).
• impact of patient’s illness on lifestyle of family or other caregiver and necessary interventions.
• availability and accessibility of adequate housing.
• access to transportation.
• readiness/availability family or other caregiver to assist with care needs of patient at home.
• availability of community or other healthcare resources to assist with care.
• need for special equipment, supplies, or medication.
• need for monitoring agents (i.e., CPS, police hold).

Assess for
actual/potential
discharge needs;
Screening criteria/
Report from previous
environment of care

Establish mutual
goals/outcomes with
patient/family

Provide patient with
discharge instruction
sheet; Ask patient family to
verbalize understanding
of instructions; assure
appropriate referrals are
made.

At the time of discharge, the following tasks will be accomplished by the disciplines indicated, if necessary:

Physicians:

• Inform the patients of the discharge date.
• Discuss the post-discharge plan of care.
• Establish time for follow-up appointment.

Nurses or Case Managers:

• Contact the patient’s family/caregiver to inform them of the discharge date and confirm transportation arrangements.
• Ensure that all necessary patient teaching has occurred.
• Confirm that a follow-up appointment has been made.
• Provide patient and family/caregiver with the discharge instruction sheet on prescribed treatments, medications (including food/drug interactions), the nutrition plan, activity level, and scheduled follow-up appointments. (All written instructions and prescriptions should be in layman’s terms. Written discharge instructions and prescriptions for discharged TDCJ offender patients should be available to the TDCJ offender's unit.)
• Ask the patient and family/caregiver to verbalize their understanding of the discharge instructions and give a demonstration of any care procedures.
• Have the patient or responsible family/caregiver sign the discharge instruction sheet attesting to the receipt of the information.
• Sign and date the form, and give the original to the patient or responsible family/caregiver.
• Document discharge summary in the medical record.
• Facilitate process described in Pharmacy Policy 20.04 for indigent patients requiring home intravenous medication therapy. This includes:

  - Social work verification of indigent status.

  - Infusion therapy nurse preformance of patient education regarding their IV therapy and catheter care with issuance of a certificate of completion.

  - Pharmacy dispensation of supplies and medications.

Social Workers:

• Contact the patient’s family/caregiver as necessary to inform them of the discharge date.
• Establish transportation home by the most appropriate means if the family is unable to provide transportation.
• Establish that the patient’s intended destination is safe and accessible.
• Confirm arrangements for any medical supplies or equipment to be provided in the home.
• Confirm transfer arrangements if the patient is being transferred to another facility, including facility acceptance, discharge prescriptions, copying pertinent parts of the medical record, completing Memorandum Of Transfer if needed.
• Make any referrals necessary for assistance from community agencies or available financial assistance and give patient or responsible caregiver a copy of the referrals made, including address and telephone number.

Respiratory Therapists:

• Determine home respiratory medical equipment needs.
• Provide patient/family teaching on medications, medical equipment, and therapy procedures to be performed at home.
• Perform oxygen assessments to determine necessity of home
• Participate in interdisciplinary discharge planning rounds and conferences.
• Advise patient and family of available community resources, if needed.
• Communicate and coordinate care with other respiratory care practitioners and healthcare providers across the continuum (e.g., Skilled Nursing Facilities, Home Health agencies, nursing homes, and TDCJ).

Physical Therapists:

• Make appropriate recommendations for equipment needs, such as ambulation devices, wheelchairs, and bedside commodes.
• Instruct patient/family/caregiver on a written home exercise program.
• Instruct family/caregiver in proper transfer/guarding and positioning techniques. Have them verbalize and demonstrate each technique.
• Make necessary recommendations for follow-up physical therapy, e.g., outpatient, home health, rehabilitation, skilled nursing facility, early intervention, or school-based therapy programs.

Occupational Therapists:

• Make appropriate recommendations for equipment needed for self-care and independence in activities of daily living.
• Instruct patient/family/caregiver in appropriate techniques to facilitate optimal safety and independence.
• Instruct patient/family/caregiver on a written home exercise/activity program.
• Instruct patient/family/caregiver in use and appropriate maintenance of splints and other orthoses. Instruction may
  occur verbally, by demonstration, and/or in writing.
• Make necessary recommendations for follow-up Occupational Therapy (e.g., outpatient, home health, rehabilitation, skilled nursing facility, early intervention, or school-based therapy programs).

Therapeutic Recreations:

• Instruct patient/family/caregiver about leisure resources available in the community.
• Make necessary recommendations for follow-up Therapeutic Recreation (e.g., skilled nursing, rehabilitation, school-based therapy, or community recreation programs).

Nutritionists:

• Participate in interdisciplinary discharge planning rounds and conferences.
• Instruct patient/family/caregiver regarding nutrition and any dietary modifications as indicated.
• Advise patient and family of available community resources, if needed.
• Make necessary recommendations for follow-up Nutrition Services (e.g., skilled nursing facility, dialysis center, or other points in the continuum of care).

Pharmacists:

• Assist medical staff with drug regimens.
• Provide patient/family/caregiver with medication information.

Registered Nurses will instruct patients prior to discharge on supply use and needs.

Uncomplicated Care - 2 Days of Supplies

• Based on the supply need assessment by the healthcare team, the patient will be given a supply list before discharge.
• The supply list will be for two days worth of supplies.
• Patients are encouraged to obtain their supplies from an outside provider. If the patient is unable to obtain their supplies from another provider, he may obtain them from the Materials Management Supply Center. The patient is responsible for the cost of the supplies or the applicable copay.
• Cancer and Ostomy patients may be referred to Social Work or Ostomy Nurse for temporary supply arrangements through American Cancer Society and Industry Patient Programs.

Complicated - More than 3 Days of Supplies

• Based on the supply need assessment by the healthcare team, the patient will be given a supply list before discharge.
• Patients are encouraged to obtain their supplies from an outside provider. If the patient is unable to obtain their supplies from another provider, he may obtain them from the Materials Management Supply Center. The patient is responsible for the cost of the supplies or the applicable copay.
• A physician order is required for 3 or more days worth of supplies issued from UTMB.
• Cancer and Ostomy patients may be referred to Social Work or Ostomy Nurse for temporary supply arrangements through American Cancer Society and Industry Patient Programs.
• Patients may be referred to Case Manager or Social Work for assistance, when necessary.

The following information must be documented in the patient’s discharge note or on appropriate approved forms in the medical record:

• Provision of all discharge-related patient/responsible caregiver education.
• Appropriateness of housing.
• Availability of transportation.
• Assessment of availability of family/other caregiver and their readiness to assist with the care of the patient at home.
• Availability of assistance from community resources, including referrals to other healthcare agencies, as appropriate.
• Availability of medical equipment, supplies, and medication as indicated.
• Follow-up plan.