Meaningful Use Norm - Discharge Planning
What is it?
Preparing for an efficient and effective discharge begins at admission. Some inpatient encounters are short and simple, with patients returning to pre-admission community supports. Others are more complex, with significant changes to patient capacity and needs. These require coordinated multidisciplinary planning to facilitate safe and timely transitions to other facilities or back to the community.
Connect Care provides decision and documentation supports that can help clinicians with discharge planning, while improving communication with healthcare providers picking up care after discharge. These tools comprise a "transitions planning package" that helps teams:
Capture standardized structured data, important to planning, about patients' known residence and supports (disposition) before admission and estimated needs after discharge.
Estimate and iteratively validate inpatients' Expected Discharge Date (EDD), Medical Readiness for Discharge (MRD) and an Expected Discharge Disposition (DISP).
Declare and share overall readiness for discharge (ORD) determinations based on achievement of nursing and allied health discharge milestones.
Focus attention on considerations and decisions affecting discharge during multidisciplinary planning (RAPID Rounds) meetings.
Incorporate key discharge plan elements into discharge communications with a standardized format and structure.
Aligh follow-up visit recommendations with predictors for early readmission (LACE readmission risk index).
Reviewing and updating alternate level of care (ALC) statuses.
Appropriate and timely use of discharge planning tools during inpatient encounters is among the Connect Care Meaningful Use Norms, with compliance feedback provided through Meaningful Use Norms Dashboards.
Why does it matter?
Good discharge planning improves patient outcomes, reduces early readmission and gets the patient to the right place at the right time. A shared Discharge Plan helps:
Set priorities by clarifying what is needed and when to enable moving to the next care setting.
Optimize use of inpatient resources, including bed management and allied health services.
Align patient/family/caregiver expectations with the health care team's preparations.
Thinking about and committing to expected discharge dates and dispositions has been shown to improve discharge planning, reduce lengths of stay, reduce readmission rates, increase patient satisfaction and smooth patient flows.
Shared expectations help caregivers set priorities by promoting reflection about what is needed, and facilitating coordinated action for smooth transitions.
Agreed expectations can more confidently be communicated to patients and families, who cite discharge dates and dispositions as important information needs.
Documented expectations help care team members time and sequence activities needed for safe discharge (e.g., patient education, medication preparation, home care initiation, etc.).
Documented and iteratively validated expectations trigger facility decisions about triage of rehabilitation, diagnostic imaging and other intervention priorities to facilitate planned discharges.
Recognizing, and declaring, when patients have completed their primary medical treatment, and so are medically ready for discharge, facilitates shifts from "acute" to "alternate level of care (ALC)" status, while:
improving the accuracy of Length of Stay (LOS) metrics, and
flagging patients requiring particular transition services to optimize total lengths of stay.
Use of Connect Care discharge planning tools ensures that all care team members work from a shared understanding of a patient's needs before admission, factors affecting readiness for discharge and needs anticipated at the expected discharge date when appropriate community supports must be readied for the expected discharge disposition.
Ensuring that a patient's medical readiness is reviewed and updated facilitates more efficient bed management, as well as allocation of transition resources within a facility.
Who is responsible?
The admitting hospital service is responsible for entering an initial expected discharge date and disposition, at admission or as soon as possible after admission. The inpatient attending prescriber (or designate) is responsible for entering a medical readiness for discharge determination and revising it with any significant change in a patient's medical plan. The inpatient hospital service is responsible for reviewing, and possibly revising, expected discharge dates, expected discharge dispositions and allied health milestones, as appropriate, during the active inpatient encounter. Any hospital service team member can be delegated to review and revise expected discharge dates and dispositions for active patients.
All disciplines (medicine, nursing, allied health) participating in an inpatient's care team should be mindful of readiness or milestone determinations for their discipline. Designating team discharge planning reps or scribes can help.
How is it done?
Expected Discharge Date (EDD)
Clinicians may worry about the accuracy of EDD guesstimates, especially early in a hospital stay. Use of Connect Care EDD editing tools gives access to built-in flash-cards that reflect the typical lengths of stay for patients with similar specialty and complexity profiles. These can be mapped to a few simple intervals by using Epic time shortcuts (T+N entered to the EDD date field where N is a number of days): ≤1 day ("T+1"), <3 days ("T+2"), <5 days ("T+4"), <10 days ("T+9"), 10+ days ("T+15")
The "Unknown" button (available in some EDD editing tools) is to be avoided because it nullifies the EDD value, affecting other discharge planning tools. Use of an estimate 15 or more days out (T+15) has the same meaning.
EDD displays with click-to-edit functionality are available at multiple points in common inpatient workflows, including patient lists, RAPID Rounds tools, admission and discharge navigators, inpatient storyboard and sidebar displays, and standard progress note templates. All EDD tools include an option to "review" (validate) an existing EDD with a single click.
Expected Discharge Disposition (DISP)
A discharge disposition is the final destination type and/or health care supports for a patient when they complete an inpatient encounter and leave the associated facility. Clinicians usually have a good sense, even very early in an admission, of the most likely disposition at discharge. At a minimum, clinicians may be able to predict a change in needs or the likelihood of return to home supports. An artificial intelligence (AI) tool can help with predictions that clinicians can elect to adopt.
DISP editors are included in all Connect Care discharge planning tools. DISP displays within discharge planning reports, and standardized documentation templates, facilitate quick click-to-edit functionality. All DISP tools automatically update a "review" (validate) date when the tools are used.
Medical Readiness for Discharge (MRD)
An inpatient is considered "medically ready" for discharge when the primary provider discipline (referred to as "medical" for simplicity) for an inpatient encounter has completed its clinical tasks and the patient is dischargeable from a "medical" perspective. Other needs (e.g., further mobility promotion, destination facility readiness, community home care readiness) may require more time to be spent in the current hospital. Accordingly, the expected discharge date may differ from the medical readiness date.
MRD editors are included in all Connect Care discharge planning tools. MRD displays within discharge planning reports (e.g., "traffic lights" patient list columns, "readiness ribbon" in discharge planning reports) and standardized documentation templates, facilitate quick click-to-edit functionality. All MRD tools automatically include a "reviewed" button that can be used to validate a MRD status without making edits.
Overall Readiness for Discharge (ORD)
Rapid Rounds patient lists and reports, as well as chart sidebar displays, provide access to interactive overall readiness indicators ("traffic lights", "readiness ribbon") that provide at-a-glance overviews of patient readiness from the perspective of all health disciplines participating in discharge planning. The visual display supports click-to-edit so that disciplines can quickly revise their readiness determinations or milestone statuses. The same editing tools are part of integrated discharge planning sidebars.
Alternate Level of Care Status (ALC)
The ALC designation effectively "stops the clock" measuring a patient's actual length of stay (LOS). This ensures that facility LOS measures reflect provision of acute care services and not days awaiting transfer to home or a more appropriate facility. Rapid Rounds lists and reports include tools for quickly initiating ALC orders, including prompting of users when a patient's medical issues have been managed and an alternate level of care should be considered.
Integrated Discharge Planning
Rapid Rounds patient lists, inpatient chart sidebar displays and interactive documentation blocks expose tools that can facilitate discharge planning during inpatient encounters. Users can review and click-to-edit key details about patient supports pre-admission, current needs and anticipated community needs. All make use of structured data shared by all inpatient disciplines have agreed to use; reducing data management burdens for any one discipline. And the discharge plan details can be pulled into progress and discharge documentation.
How is compliance promoted?
Feedback about adherence to discharge planning meaningful use norms is provided to through a "Connect Care Meaningful Use Norms Feedback" display available in the Hyperspace "Dashboards" activity, available to all inpatient providers. A "personal" dashboard provides individualized feedback to the currently signed-on prescriber, while a "group" dashboard provides performance metrics that can be aggregated at the level of departments (units), hospital services or facilities. This feedback information is easiest to access through the use of "target" icon hyperlinks embedded within discharge planning tools and workflows.
Discharge planning behaviours are tracked through the use of a data "snapshot" taken every morning at ~03:00. This
The following measures are included in meaningful use dashboards:
EDD Entry
Percentage of patients with an EDD entered by the admitting hospital service within different time periods referenced to the time of entry of admission or discharge orders.
EDD Not Set
Percentage of patient days in which an EDD has not been entered.
Medical Readiness for Discharge Entry
Percentage of patients with a MRD entered by the admitting hospital service within different time periods referenced to the time of entry of admission or discharge orders.
Medical Readiness for Discharge Not Set Days
Percentage of patient days in which a MRD has not been entered.
NOT Medically Ready but ALC Days
Percentage of patient days in which a patient is in ALC status but NOT marked medically ready for discharge.
Medically Ready but NOT ALC Days
Percentage of patient days in which a patient is medically ready for discharge but has NOT been marked ALC.
Expected Discharge Disposition Not Set Days
Percentage of patient days in which a DISP has not been entered.
Conditional Discharge Workflow Days
Percentage of patient days in which a conditional discharge order has been entered and is in active or pending status.
Derivation of these metrics is explained further in the Connect Care Builder Handbook, with links to data quality definitions.