Discharge Planning

Hospitals all over the country record high numbers of people being admitted due to a particular health condition. These admissions are mainly not predicted hence referred to as emergency admissions. Mr. Brown suffers from chronic heart failure which exhibit unpredictable symptoms which will require the patient to seek for quick clinical need within a short notice (NHS Connecting for Heath, 2010). Unfortunately, in most cases, patients are re-hospitalized after being discharged. Jencks, Williams and Coleman (2009) reveal that out of five elderly patients, at least one of them is re-hospitalized within 30 days after being discharged from the hospital. This has been very common and expensive (Boutwell & Hwu, 2009). Patients suffering from chronic heart failure are no exceptions. Mr. Brown in particular is about to be discharged and it is important that he avoids readmission in hospitals. Therefore, in this paper I will discuss the package of care within a discharge plan, the ten principles of discharge, MDT involved, strategies that will empower and support Mr. Brown in his recovery and their significance to him and to others, and thereafter designing a discharge plan.

It is not surprising that Mr. Brown suffers from chronic heart failure condition when you consider that he is 67 years old and showed symptoms for the same heart condition which included shortness of breath, chest pains and feeling fatigued (SIGN, 2007; Dickstein, Cohen-Solal, Filippatos, McMurray, Ponikowski, Poole-Wilson,

Stro¨mberg, van Veldhuisen, Atar, Hoes, Keren, Mebazaa, Nieminen, Priori, Swedberg, 2008).  He also had a medical history of suffering from hypertension and ischemia disease which set a stage for the development of the disease. The coronary artery bypass that was done 10 years ago might have also led to chronic heart failure. NICE (2010) reports that coronary artery disease is a major cause of heart failure in the UK.

Generally, Mr. Brown might be having a structural or functional cardiac or non-cardiac disorder that makes the heart not able to meet “physiological demands for increased cardiac output” (SIGN, 2007). Therefore, Mr. Brown is in need of a complex discharge plan. The discharge plan will contain package of care that are elaborate and will involve health and social services, voluntary organizations, funding issues and more. His plan has to be individualized because individualized discharge plan have been found to reduce re-admission to hospitals by 15% (Sheppered, McClaran, Phillips, Lannin , Clemson, McCluskey, Cameron  & Barras, 2010). The individualized discharge plan is also recommended by Bell, Ervin and Lesperance (2005) and is a form of self-management that will help Mr. Brown to take control of his condition (Corben & Rosen, 2005).

The discharge plan for Mr. Brown must involve assessment and evaluation of his condition. His medical status must be monitored by well coordinated and organized careers. Medication for Mr. Brown must be given to him at appropriate times. Communication in the discharge plan among the patient, careers and family is part of a care package that will enhance a smooth discharge process.  Other packages involve physical activity, outpatient medical services, and family time and therapy sessions (Appendix 1).

In order to ensure that Mr. Brown’s road to recovery improves tremendously he would need a discharge plan. The plan would also prevent cases of re-hospitalization (Griffith, Kwok, Lee, Lee & Woo, 2008) and in turn empower him or his family to provide care. Factors that should be considered in formulating a discharge plan for Mr. Brown include his health condition and how to do away with his chest pain, depression, fatigue and laziness, weight loss and loss of appetite. There is shortness of breath and hypertension. The period of time that will he will spend in the hospital must be considered because it will ensure the multidisciplinary team (MDT) work in an organized way and be responsible.

The MDT who will be involved in enhancing package of care to Mr. Brown will include physiotherapist, social services, coordinator discharge, registered nurse, community matron, pharmacist, doctor, general physicians, dieticians, cardiac specialist nurse, OT and voluntary organisations. These members carry out a wide range of medical intervention services such as the nurse-led programs, patient education, follow-ups, patient education, medication review, nutrition, enhanced monitoring, exercise, physical, speech therapy, and occupational and  social work (Boutwell & Hwu, 2009). When these interventions are effectively carried out by the MDT, rates of re-hospitalization will reduce by approximately 20% to 25 % (Holland, Battersby, Harvey, Lenaghan, Smith & Hay, 2005).

The Department of Health (2010) outlines ten principles of discharge that can be used as a guide while creating a discharge plan. The first step to make immediately Mr. Brown was admitted in the hospital was to start planning the discharge process. The second step is to determine the type of discharge plan which we have found out to be complex because his condition has worsened and would need a close monitoring and care. This discharge plan must be developed within 24 hours after being granted admission to the hospital. The fourth step in discharge planning is coordination and handing over of responsibilities among the MDT members.

Thereafter, a date is set which we will expect Mr. Brown to be discharged. This fifth step should be done within 24 – 48 hours of admission. The sixth step in the discharge process is to review the discharge plan on a daily basis, taking necessary action, checking how the patient progresses. The seventh key principle in a discharge plan involves consulting the patient and the careers while making a medical decision so that the care given is customer centered. The plan discharge should be created to involve the careers provide services over seven days so as to ensure that there is continuity of care for the patient. The ninth step is to ensure that you use a discharge checklist that is 24 – 48 hours prior to transfer. The ten principle of discharge guide you in making decisions to discharge stable patients every day.

Involving the patient and the family in the discharge plan is important. When they are all involved, they would be able to make decisions that would correlate with their expectations and feel satisfied (Bauer, Fitzgerald, Haesler et al., 2009). Mr. Brown’s sons and the rest the family are preparing for a discharge of Mr. Brown. Being involved in the discharge plan will reduce or prevent any surprises. They too will take responsibilities of taking care of him hence the discharge plan offers an opportunity to familiarize with packages of care and even to learn some of them.

It is vital for Mr. Brown and family to be present when there is presentation of a summary care and medical report during the discharge process. They will therefore get information about the patient’s lifestyle during his stay in the hospital and his medication procedure. In addition, it summarizes some side effects and behavioral characters of the patient during his stay and how they were managed. All the information in the summary care will guide the family and also Mr. Brown to manage any kind of medical problem or abnormal character that arises.

The family and Mr. Brown involvement in the discharge process will save time and avoid disorganization. This means that communication will be easier. Everyone will work to achieve their goals, understand any plans as soon as possible, and arrangement for the discharge plan will be successful. There will be no delay in terms of organizing transport, preparing homes and registering Mr. Brown in an outpatient medical service.

In addition to this, the process will enable them come across caring services that they may require in supporting themselves in provision of care for Mr. Brown. Families and patients always feel powerless, anxious and insignificant. Things happen around them but not with them (DH, 2003). These individuals’ participation in discharge planning process will allow them obtain information that will empower them and guide them in making informed decisions (Department of Health, 2010).

The discharge plan is aimed to resume the services that were offered in the hospitals to be also offered in homes where the patients will reside. Mr. Brown’s conditions involved a great deal of combining different kind of medicines, making assessments and being monitored regularly. Involving the family and also the patient in the process of planning a discharge will help them gain some medical, social and nursing skills that they can offer to their loved ones.

Health institutions want to build trust and professional relationship with their patients in order to facilitate quick recovery. Communication is very important if Mr. Brown wants to heal. It involves following instructions, understanding and giving feedbacks. Mr. Brown’s condition and symptoms became visible through communication. He presented his real concerns and worries about his conditions. If he would not have done that then the condition would have totally deteriorated followed by death.

Communication involves showing compassion to the patients. The more you empathize and exhibit more compassion, the stronger the bond among the patient, families and medical carers. The bond of trust and respect will develop (Welsh Assembly Government, 2008).

Effective communication brings understanding among the different members of the MDT. Each unit is able to perform its assigned work appropriately and at the right time. Record keeping as part of communication will enable continuity of a treatment process of a patient. It is a medium through which different medical practitioners are able to communicate even without meeting each other. In the long run the medical condition of a patient improves.

Through communication, Mr. Brown is able to receive any information concerning his condition. This family is also given feedback to any enquiries pertaining Mr. Brown’s health status. The family and Mr. Brown are able to synthesize the information given and make reasonable decision that will contribute towards his health improvement. To ensure that there will be a smooth transition and safe discharge in this scenario, communication must be clear and brief, done very early and is honest. Clear messages are easy to understand. Communication should also be done very early, for example the discharge date, so that preparations and arrangement for discharge are done earlier. Information given to Mr. Brown should be authentic. Honest results, reports and assessment will establish trust and it encourages the family and Mr. Brown to accept any decision from the hospital concerning discharge.

Telemedicine is a very good component of a multidisciplinary programme for congestive heart failure. It involves both telecare and telehealth. Telecare means that I will be using equipment to support Mr. Brown at home but having to maintain regular contact with the health institution through telephone. On the other hand, telehealth means that I will have to ensure that there is equipment that will be used in monitoring vital signs in Mr. Brown such as his heart rate then sending data to the health institution for interpretation (Purdy, 2010). As a form of communication, telemedicine will result in hospital admission reduction (Deshpande, Khoja, McKibbon & Jadad, 2008).

Patients with chronic heart failure seek re-hospitalization after being discharged. Mr. Brown suffers from chronic heart failure and experiences shortness of breath and hypertension. In addition he has lost his appetite and weight. Because this type of a health condition requires special and complex need, Mr. Brown will be put under a complex discharge plan. The discharge plan will be able to assess and evaluate his condition frequently, monitor medical status, guide in medication, and allow physical activity, outpatient medical services, and family time and therapy sessions (Appendix).  The MDT who will be involved in enhancing package of care to Mr. Brown will include physiotherapist, social services, coordinator discharge, registered nurse, community matron, pharmacist, doctor, general physicians, dieticians, cardiac specialist nurse, OT and voluntary organizations.

The ten principles for discharge includes: start planning immediately, determining the type of discharge plan, developing it within 24 hours after admission, coordination, discharge date, review\wing the discharge plan daily, taking necessary action, checking progress of patients, consulting, provision of services over seven days, using a discharge checklist and discharging patients. Mr. Brown and family should be involved in the whole process of discharge so as to allow successful transition of care. Communication also plays an important role in understanding and relaying information among the patient, the family and the medical practitioners.



Discharge Plan


Name of patient……………………………………………………………………..

Sex………………………..                                       Age……………………….

Health Condition……………………………….

Date of Admission…………………………….

Date of Discharge……………………………..

The care plan will be carried on a 5-day cycle
Time Day 1 Day 2 Day 3 Day 4 Day 5
5 – 8 am Admission


Morning walking exercise, Medication



Therapy session, monitoring of air and body fluid levels, medication



Light jogging/ running


Weight lifting, walking/ running/jogging etc
9 – 12 pm Electrocardiogram (ECG) assessment, chest X-ray, Arterial Blood gas Analysis, echocardiography assessment

Functional capacity, fluid retention levels,

Health education, medication,

Heart rate, oxygenation and respiratory monitoring


Quiet time, family time Assessment and evaluation ( laboratory tests e.g. body nutrition assessment, cardiac rhythm, cognitive status etc.), medication and treatment Self-care management training
12-2 pm Lunch Break   Lunch Break    
3 – 5 pm Orientation and Friendship development Medication,

Group therapy

Health education with family,

Outdoor activities e.g. taking a walk, playing fun games etc

Result analysis report discussion with patient, family and medical staff Rest time

**review of the care plan with the patient and family

6 – 8 pm Supper Medication



Medication, oxygenation and respiratory assessment


Medication, body assessment and evaluation

Supper, medication Supper


From 8 pm

Silent Night

**review of the care plan with the patient and family will be done frequently as from the fifth day for any indication of health stability.


Medication of Mr. Brown will include administration of:

  • Angiuotensin-converting enzyme (ACE) Inhibitors which can also be combined with aspirin
  • Aspirin
  • Hydralazine in combination with isosorbide dinitrate if he shows ACE intolerance.
  • aldosterone antagonist
  • Diuretics/ loop diuretics/ metolazone to relieve oedema and dyspnoea
  • Beta-blockers which will immediately stopped when he shows any sign of asthma, heart block or hypotension. Bisoprolol, carvedilol and nebivolol will be a good start (SIGN, 2007).


The assessment, evaluation and exercise care services will be done by the following MDT:


  • Physiotherapist
  • Social workers
  • Discharge Coordinator
  • Registered nurse
  • Cardiac specialist nurse
  • Pharmacist
  • Doctor
  • General physicians
  • Dieticians
  • Community matron


Bauer M, Fitzgerald L, Haesler E, et al. (2009). “Hospital discharge planning for frail older people and their family. Are we delivering best practice? A review of the evidence.” Journal of Clinical Nursing. Vol. 18 Issue 18, pp. 2539–46.

Bell, S. Ervin, N. & Lesperance M. (2006). “Heart Failure and weight gain monitoring.” Lippincotts Case Management. Vol. 10, pp. 287-93.

Boutwell, A. Hwu, S. (200).Effective Interventions to Reduce Rehospitalizations: A Survey of the Published Evidence. Cambridge, MA: Institute for Healthcare Improvement;

Corben S, Rosen R (2005). Self-Management for Long-Term Conditions: Patients’ perspectives on the way ahead. London: The King’s Fund.

Deshpande, A., Khoja, S., McKibbon, A. & Jadad, A. (2008). Real-time (Synchronous) Telehealth in Primary Care: Systematic review of systematic reviews. Technology Report No 100. Ottawa: Canadian Agency for Drugs and Technologies in Health.

DH (2003) Discharge from hospital: Pathway, process and practice. DH.

Dickstein, K., Cohen-Solal, A., Filippatos, G., McMurray, J., Ponikowski, P., Poole-Wilson, P., Stro¨mberg, A., van Veldhuisen, D., Atar, D., Hoes, A., Keren, A., Mebazaa, A., Nieminen, M., Priori, S. & Swedberg, K. (2008). “ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM).” European Heart Journal. Vol. 29, pp. 2388–2442

Griffith, S., Kwok, T., Lee, D., Lee, J. & Woo, J. (2008). “A randomized controlled trial of a community nurse-supported hospital discharge programme in older patients with chronic heart failure.” Journal of Clinical Nursing. Vol. 17 Issue 1, pp. 109-17.

Holland, R., Battersby, J., Harvey, I., Lenaghan, E., Smith, J. & Hay, L. (2005). Systematic review of multidisciplinary interventions in heart failure. Heart. Vol. 91 Issue7, pp. 899-906.

Jencks, S., Williams, M. & Coleman, E. (2009). Rehospitalizations among patients in the Medicare fee-forserviceprogram. New England Journal of Medicine. Vol. 360 Issue 14, pp. 1418-1428.

NHS Connecting for Health (2010). ‘Data model and dictionary service’. Available at:www.datadictionary.nhs.uk/data_dictionary/attributes/a/add/admission_method_de.asp?shownav=1

NICE (2010). Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care. Manchester: National Institute for Health and Clinical Excellence

Purdy, S. (2010). Avoiding hospital admissions: What does the research evidence say? Cavendish Square London: The King’s Fund.

SIGN (2007). Management of chronic heart failure: A national clinical guideline. Edinburgh: Scottish Intercollegiate Guidelines Network

Shepperd, S., McClaran, J., Phillips, C., Lannin, N., Clemson, L., McCluskey, A., Cameron, I. & Barras, S. (2010). ‘Discharge planning from hospital to home (Cochrane Review)’. Cochrane Database of Systematic Reviews, issue 1, article CD000313. DOI: 10.1002/14651858.CD000313.pub3.

Welsh Assembly Government (2008) Passing the baton: A practical guide to effective discharge planning. Welsh Assembly Government.