The Singapore Family Physician
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Vol 3 No. 37 - Integrated Eldercare Course
Discharge Planning in Integrated Care
The Singapore Family Physician
Vol 3
No 37
- Integrated Eldercare Course
27
- 31
1 July 2011
0377-5305
The discharge of the patient from the hospital to the community or step down care facilities is a critical point in patient care. The discharge process is especially critical for elderly patients and patients with multiple co-morbidities and impaired function. Inappropriate discharge destination and incomplete communication with patients and ambulatory care can lead to adverse outcomes like unscheduled readmissions, emergency department visits and adverse events. Know the goals of discharge planning: reduce unnecessary hospital length of stay, prevent adverse outcomes after discharge, and co-ordinate services between hospital and community, bridging the gap between hospital and discharge destination. Discharge planning process should start at admission. Screen for the higher risk patient and intervene specifically to reduce the risks. Go through the elements of discharge planning: determine the post discharge site of care, do medication reconciliation, educate patient, create a useful discharge summary. Be clear of the doctor’s role in discharge planning.