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  1. 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.

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  2. Educate the patient and family in plain language about the patient’s condition, the discharge process, and next steps 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.

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  3. During your stay, your doctor and the staf will work with you to plan for your discharge. You and your caregiver (a family member or friend who may be helping you) are important members of the planning team. You can use this checklist to prepare for your discharge.

    • Patients with Complex Medical Conditions
    • Elderly Or Frail Patients
    • Patients with Limited Support Systems
    • Transitions to Other Healthcare Facilities
    • Patients with Mental Health Conditions

    For patients with multiple comorbidities, chronic diseases, or those recovering from major surgeries, a well-structured discharge plan is essential to address the various aspects of their care and support during recovery.

    Older adults or patients with frailty may require additional support and assistance in managing their daily activities and medical care. A comprehensive discharge plan ensures their unique needs are met during the transition.

    For patients with limited or no support from family or friends, a discharge plan can help coordinate the necessary services and resources, such as home health care or community-based support programs, to ensure their well-being and safety after hospitalization.

    A detailed discharge plan outlines the needed services when patients require ongoing care at a rehabilitation center, skilled nursing facility, or long-term care facility. It ensures continuity of care during the transfer.

    Discharge planning for mental health conditions involves coordinating care with mental health professionals and ensuring appropriate support for the patient and their caregivers. Healthcare practitioners can effectively document and communicate all necessary information about a patient's care and recovery using a Discharge Plan Template. This ensur...

  4. During your stay, your doctor and the staff will work with you to plan for your discharge. You and your caregiver (a family member or friend who may be helping you) are important members of the planning team. You and your caregiver can use this checklist to prepare for your discharge.

  5. The facility must develop and implement an effective discharge planning process that focuses on the resident’s discharge goals, the preparation of residents to be active partners, and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions.

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  7. www.caregiving.org › 05 › CMS_Discharge_PlanningPlanning for Your Discharge

    Planning for Your Discharge During your stay in a hospital, nursing home, or other health care setting, the staff will work with you to plan for your discharge.

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