| Learning Objective #1: List the characteristics and components of successful discharge planning to support discharge readiness in patient and family transition for the hospitalized adult. | |||
| Learning Objective #2: Describe literature supported domains to imbed in a computerized clinical documentation system that support discharge planning and promote readiness in patient and family outcome. |
Method: As part of the ACW (Aurora, Cerner, UW-Milwaukee) Knowledge-Based Nursing Initiative project, a systematic literature review of over 300 publications on discharge planning and discharge readiness was conducted. The results were synthesized into evidence-based, clinical practice recommendations using the nursing process framework of assessment, diagnosis, intervention and outcome. The recommendations are patient and family focused and sequenced in order to achieve an integrated package of care delivery recommendations across the continuum of care.
Outcomes: The key characteristics and components of successful discharge planning and readiness supported by research include: discharge planning is required for all patients and families/caregivers, it should begin at admission, and it should include systematic monitoring, interdisciplinary collaboration and post discharge support to reduce unplanned readmission. These characteristics reflect the fact that nurses play a critical role in the interdisciplinary preparation of patients, and families for discharge. A Synthesis Flow Chart of the clinical practice recommendations for discharge planning/readiness is displayed including the key components essential for achieving successful care transition from admission to discharge.
Future Work: As a next step, the evidence-based clinical practice recommendations will be embedded in an electronic clinical information system with decision support. After that, as part of the ACW project, clinical research will be conducted on the use of and outcomes of the clinical practice recommendations. This work supports recent policy recommendations regarding the need for data to demonstrate the quality of nursing practice and patient /family outcomes.