Learning Objective #1: The learner will be able to identify successful strategies for identifying service gaps in discharge planning

Learning Objective #2: The learner will be able to describe interprofessional interventions that provide continuity of care in the discharge planning process.

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One of the most challenging aspects of discharge planning is the communications among institutional health care providers and between these providers and the community. Despite the assistance of unit-based case managers, nurses spend considerable time and energy on the discharge process, and with complex patients, this process can be an enormous drain of resources and put patients at risk. This poster will provide an overview of a systems approach that was used to analyze the multiple components and process steps involved in efficacious discharge planning for complex, pediatric neuroscience patients. The poster will focus specifically on leadership and management tools and skills that were used to orchestrate an interdisciplinary team that identified gaps in the discharge process and developed, implemented, and evaluated strategies to address these gaps. This successful project, which took place over the course of a year, resulted in a new discharge planning protocol with accompanying patient education sheets, a phone follow-up service, and advanced practice nurse coordination of neurosciences outpatient clinics. This systems analysis provided nursing leadership with a means to demonstrate the types of services that significantly influence patient outcomes.