1. Zangerle, Claire M. MBA, MSN, RN

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Patient care is delivered in a variety of settings across the continuum. Increasingly, less of that care is provided within the four walls of an acute care hospital. However, it's within those four walls that postacute placement decisions are made, which impact a patient's healthcare journey over time. With laser focus on decreasing hospital lengths of stay and readmissions, failing at care coordination wreaks havoc for the patient, the healthcare system, and the advancement of better transitions.

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Postacute care patient placement

Every day, patients are transitioned from one care setting to another with the ultimate goal of improving care quality and reducing readmissions. The appropriate placement in that transition has significant impact on patient care outcomes, including overall satisfaction.1 Care managers collaborate with physicians and clinical nurses to determine the best care setting upon hospital discharge. The placement decision tree may be more of an art than a science. Although both are important in care transitions, utilizing a discharge planning tool may be the best approach to bring the art and science together.


There isn't one standardized, universally utilized tool that includes all of the defining elements for best setting placement; however, there are some excellent instruments available. These tools possess valuable characteristics for postacute care placement, readmissions, and transition management. Key components of discharge tools ensure a comprehensive view of the patient, including a clinical and social picture, allowing for appropriate placement that captures the patient's needs.


Recently, the American Hospital Association (AHA) published a white paper highlighting the efforts of five organizations to improve care transitions through developing and implementing discharge planning tools. Feeling the pressure of shifts in payment models from fee-for-service to episodes of care payments, these organizations proactively sought ways to make care transitions efficient and effective. These efforts focused on discharge dispositions, ensuring that patients were placed in the right setting at the right time. Ultimately, achieving the Triple Aim-better care at lower costs with an improved experience-was the guiding principle.2


Identifying the tools of the trade

An AHA technical advisory panel convened to study innovative discharge planning tools, inviting five organizations to share their findings on the use of these instruments. The organizations shared commonalities in their tool design that included aligning with organizational culture and a focus on reducing readmissions by getting the patient to the right care setting. Table 1 outlines the primary objectives and domains measured using each tool. The domains represent the differences in the tools, but the goal is the same: appropriate postacute patient placement.

Table 1: Discharge t... - Click to enlarge in new windowTable 1: Discharge tool primary objectives and domains measured

Although challenges in tool development and implementation were noted, there were valuable lessons learned for developing a robust discharge planning tool with optics around organizational culture. These included:


1. Base postacute placements on the clinical needs of the patient.


2. Interdisciplinary clinical considerations must be incorporated into discharge planning tools.


3. Discharge planning tools must not present an administrative burden.


4. Focus discharge planning tools on an outcome that includes optimizing the hospital stay and reducing the need for postacute care services.


5. Utilize a tool that collects standard information to support a reduction in variance of postacute placement and reduce readmissions.



Nurses in position

Nurses are uniquely positioned to work with care managers to plan the smooth transition of the patient from the hospital to the next setting. They're also the ones who get to know the patient on different levels and can provide valuable information along the acute care journey. The best approach to discharge planning is to focus on the present while looking to the future.




1. Naylor MD, Sochalski JA. Scaling up: bringing the transitional care model into the mainstream. Issue Brief (Commonw Fund). 2010;103:1-12. [Context Link]


2. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. [Context Link]


3. American Hospital Association. Private-sector hospital discharge planning tools. [Context Link]