Title: 
Headings: Care Transitions from Hospital to Home: IDEAL Discharge Planning
Car
e
 
Transitions
 
from
 
Hospital
 
to
 
Home:
 
IDEAL
 
Discharge
 
Planning
 

Implementation
 
Handbook
 

Guide
 
to
 
Patient
 
and
 
Family
 
Engagement
 

Table
 
of
 
Contents
 

Introduction
 
----------------------------------------------------------------------------------------------------------------
 
1
 

Rationale
 
for
 
the
 
IDEAL
 
Discharge
 
Planning
 
Strategy
 
-------------------------------------------------------
 
8
 

Implementing
 
the
 
IDEAL
 
Discharge
 
Planning
 
Strategy
 
---------------------------------------------------
 
14
 

Interested
 
in
 
improving
 
transitions
 
from
 
hospital
 
to
 
home?
 

IDEAL
 
Discharge
 
Planning
 

Introduction
 

Overview
 
of
 
the
 
IDEAL
 
Discharge
 
Planning
 
strategy
 

Guide
 
to
 
Patient
 
and
 
Family
 
Engagement
 
::
 

What
 
are
 
the
 
IDEAL
 
Discharge
 
Planning
 
tools?
 

What
 
is
 
the
 
IDEAL
 
Discharge
 
Planning
 
process?
 

Strategy
 
4:
 
IDEAL
 
Discharge
 
Planning
 
(Implementation
 
Handbook)
 

What
 
to
 
do?
 

Discharge
 
planning
 
meeting
 

Day
 
of
 
discharge
 

Who
 
does
 
it?
 

Blank
 
cell.
 

Hospital
 
identifies
 
one
 
person
 
or
 
a
 
combination:
 
Nurse,
 
patient
 
advocate,
 
discharge
 
planner
  

Blank
 
cell.
 

What
 
are
 
the
 
resources
 
needed?
 

Rationale
 
for
 
the
 
IDEAL
 
Discharge
 
Planning
 
Strategy
 

What
 
are
 
the
 
key
 
challenges
 
related
 
to
 
discharge?
 

Helpful
 
Links
 

TransitionHomeforHF.aspx

How
 
to
 
prevent
 
adverse
 
events
 
after
 
discharge
 

How
 
does
 
the
 
IDEAL
 
Discharge
 
Planning
 
strategy
 
improve
 
the
 
discharge
 
process?
 

How
 
does
 
engaging
 
the
 
patient
 
and
 
family
 
differ
 
from
 
a
 
typical
 
discharge
 
process?
 

Guide
 
Resources
 

Implementing
 
the
 
IDEAL
 
Discharge
 
Planning
 
Strategy
 

Step
 
1:
 
Form
 
a
 
multidisciplinary
 
team
 
to
 
identify
 
areas
 
of
 
improvement
 

Engage
 
patients
 
and
 
families
 
and
 
unit
 
staff
 
in
 
the
 
process:
 
Establish
 
a
 
multidisciplinary
 
team
 

Guide
 
Resources
 

Assess
 
family
 
visitation
 
policies
 

Assess
 
current
 
views
 
on
 
the
 
discharge
 
process,
 
including
 
how
 
patients
 
and
 
family
 
members
 
are
 
engaged
 

Recognize
 
challenges
 
in
 
changing
 
staff
 
behavior
 

Helpful
 
Link

Set
 
aims
 
to
 
improve
 
discharge
 
planning
 

Guide
 
Resources
 

Tool
 
1:
 
IDEAL
 
Discharge
 
Planning
 
Overview,
 
Process,
 
and
 
Checklist
 

Tool
 
2a
 
and
 
2b:
 
Be
 
Prepared
 
to
 
Go
 
Home
 
Checklist
 
and
 
Booklet
 

Tool
 
3:
 
Improving
 
Discharge
 
Outcomes
 
With
 
Patients
 
and
 
Families
 

Step
 
2:
 
Decide
 
on
 
how
 
to
 
implement
 
the
 
IDEAL
 
Discharge
 
Planning
 
strategy
 

Decide
 
on
 
how
 
to
 
adapt
 
the
 
IDEAL
 
Discharge
 
Planning
process
 
for
 
your
 
hospital
 

Take
 
It
 
Further
 

Guide
 
to
 
Patient
 
and
 
Family
 
Engagement
 
::
 

Handbook)

Step
 
3:
 
Implement
 
and
 
evaluate
 
the
 
IDEAL
 
Discharge
 
Planning
 
strategy
 

Inform
 
staff
 
of
 
changes
 

Train
 
staff
 

Strategy
 
4:
 
IDEAL
 
Discharge
 
Planning
 
(Implementation
 
Handbook)
 

Distribute
 
tools
 
and
 
incorporate
 
key
 
principles
 
into
 
practice
 

Assess
 
implementation
 
intensely
 
during
 
the
 
first
 
month
 
and
 
periodically
 
after
 
that
 

Get
 
feedback
 
from
 
nurses,
 
patients,
 
and
 
families
  

Refine
 
the
 
process
  

Key
 
to
 
Success
 

Case
 
Study
 
on
 
IDEAL
 
Discharge
 
Planning:
 

Advocate
 
Trinity
 
Hospital
 

Strategy
 
4:
 
IDEAL
 
Discharge
 
Planning
 
(Implementation
 
Handbook)
 

References
 


Content: Throughout
 
this
 
handbook,
 
we
 
include
 
examples
 
and
 
real-world
 
experiences
 
from
 
Advocate
 
Trinity
 
Hospital
 
in
 
Chicago,
 
IL,
 
which
 
implemented
 
IDEAL
 
Discharge
 
Planning
 
as
 
part
 
of
 
a
 
year-long
 
pilot
 
project. Overview
 
of
 
the
 
IDEAL
 
Discharge
 
Planning
 
strategy
 
The
 
goal
 
of
 
the
 
IDEAL
 
Discharge
 
Planning
 
strategy
 
is
 
to
 
engage
 
patients
 
and
 
family
 
members
 
in
 
the
 
transition
 
from
 
hospital
 
to
 
home,
 
with
 
the
 
goal
 
of
 
reducing
 
adverse
 
events
 
and
 
preventable
 
readmissions. The
 
IDEAL
 
Discharge
 
Strategy
 
can
 
be
 
used
 
on
 
its
 
own
 
or
 
in
 
conjunction
 
with
 
other
 
initiatives,
 
including
 
RED
 
(Re-
engineering
 
Discharge),
 
the
 
Care
 
Transitions
 
program,
 
and
 
BOOSTing
 
(Better
 
Outcomes
 
for
 
Older
 
Adults
 
Through
 
Safe
 
Transitions)
 
Care
 
Transitions. The
 
Guide
 
was
 
developed
 
for
 
the
 
U.S.
 
Department
 
of
 
Health
 
and
 
Human
 
Services’
 
Agency
 
for
 
Healthcare
 
Research
 
and
 
Quality
 
by
 
a
 
collaboration
 
of
 
partners
 
with
 
experience
 
in
 
and
 
commitment
 
to
 
patient
 
and
 
family
 
engagement,
 
hospital
 
quality,
 
and
 
safety. Led
 
by
 
the
 
American
 
Institutes
 
for
 
Research,
 
the
 
team
 
included
 
the
 
Institute
 
for
 
Patient
 
and
 
Family-Centered
 
Care,
 
Consumers
 
Advancing
 
Patient
 
Safety,
 
the
 
Joint
 
Commission,
 
and
 
the
 
Health
 
Research
 
and
 
Educational
 
Trust. Other
 
organizations
 
contributing
 
to
 
the
 
project
 
included
 
Planetree,
 
the
 
Maryland
 
Patient
 
Safety
 
Center,
 
Aurora
 
Health
 
Care,
 
and
 
Emory
 
University
 
Hospital. Guide
 
to
 
Patient
 
and
 
Family
 
Engagement
 
:: The
 
IDEAL
 
Discharge
 
Planning
 
strategy
 
highlights
 
the
 
key
 
elements
 
of
 
engaging
 
the
 
patient
 
and
 
family
 
in
 
discharge
 
planning: Include
 
the
 
patient
 
and
 
family
 
as
 
full
 
partners
 
in
 
the
 
discharge
 
planning
 
process
 
Discuss
 
with
 
the
 
patient
 
and
 
family
 
five
 
key
 
areas
 
to
 
prevent
 
problems
 
at
 
home: Describe
 
what
 
life
 
at
 
home
 
will
 
be
 
like


Review
 
medications


Highlight
 
warning
 
signs
 
and
 
problems


Explain
 
test
 
results


Make
 
followup
 
appointments

Educate
 
the
 
patient
 
and
 
family
 
in
 
plain
 
language
 
about
 
the
 
patient’s
 
condition,
the
 
discharge
 
process,
 
and
 
next
 
steps
 
at
 
every
 
opportunity
 
throughout
 
the
 
hospital
 
stay
  
Assess
 
how
 
well
 
doctors
 
and
 
nurses
 
explain
 
the
 
diagnosis,
 
condition,
 
and
 
next
steps
 
in
 
the
 
patient’s
 
care
 
to
 
the
 
patient
 
and
 
family
 
and
 
use
 
teach
 
back.