Coordinating the Chaos of Discharge Planning

 As I continue to approach my graduation this coming April, one aspect of medical social work that is evident to be most crucial, chaotic, and rewarding is discharge planning. It is not just about scheduling transportation; It's about crafting a strategic plan while also collaborating with multiple different hospital disciplines. You could picture this concept as playing a complex game, one that requires the ability to solve complex puzzles on hard mode. You must practice multi-tasking by think ahead while working with limited resources. 

Rule 1: The Initial Assessment is the First Piece of the Puzzle

When solving complex puzzles, you analyze the playing field before initiating that first move. In the field of medical social work, the assessment step is everything. You can't solely think about the patient's diagnosis; you have to paint the picture. 

• Home Environment
• Barriers: Does the patient have any stairs on the inside or outside of the home? Do they live alone with significant mobility issues? 
• Social Environment
• Does the patient have family members? Do they have community support? 
• Financial
• Is the patient able to afford their durable medical equipment (DME)? Are they able to obtain their prescriptions? 

If you forego this step, you will inevitably run into discharge barriers and delays. It is wise to prioritize discussing this step with the patient early on during their admission. 

Rule 2: Don't Put All Your Eggs in One Basket

In puzzle games, if you only farm one resources (like currency within the game), your enemy will shut you down with ease. When crafting a discharge plan, putting all your focus on one referral to a skilled nursing facility (SNF), increases the chance of delays in discharge and patient care. The status of a SNF can change drastically overnight. It's wise to consider backup options:

• Plan A: Long-Term Acute Care Hospitalization (LTACH)
• Plan B: Inpatient Rehab (IPR)
• Plan C: Skilled Nursing Faility (SNF)

Practicing diversity with strategic planning is the key to limiting readmissions! 

Rule 3: Effective Communication Skills

When establishing a safe and sufficient discharge plan, collaborating with other healthcare disciplines while managing their exactions, is perhaps the most challenging part of the job. While all of the disciplines have the same end goal, each discipline within the hospital still has their own set of goals too. This is where practicing Motivational Interviewing (MI), can be most beneficial. You are not merely telling the patient where they will be sent to; you are guiding them to make an informed decision on their own. You are also helping them think about what they believe is the best discharge plan for them. 

Conclusion: The Satisfaction of the End Result

The stress that comes along with the job is often quite high; however, it can be very rewarding when everyone collaborates effectively and establish a discharge plan that ensure the patient's success. Now, I would like to hear from my fellow collogues: What is the most common discharge barrier that you experience, and how do you go about overcoming these obstacles? 

Please share your experience in the comments!