What is a Discharge Planning Assessment?

A discharge planning assessment is a process commonly used in healthcare, especially by nurses, to evaluate the overall health and life situation of adult patients. This assessment aims to understand how various factors in their lives, such as their physical and mental health, social environment, and lifestyle choices, influence their overall well-being. By examining these aspects, healthcare professionals can identify potential challenges and risks that may hinder the patient's ability to maintain a healthy lifestyle. This assessment helps develop a tailored discharge plan that considers the patient's specific needs and resources available to them.

During these assessments, the healthcare provider will inquire about various aspects of the patient's life. This includes their home life, living situation, support systems, transportation arrangements, financial status, and any concerns regarding food security. Additionally, the provider will gather information about the medical equipment the patient uses and inquire about their preferred pharmacies and healthcare providers. They will also ask if the patient faces any challenges in accessing medications, such as rationing or affordability issues. Furthermore, the healthcare provider will assess the patient's habits, such as smoking or use of street drugs.

This assessment is crucial for the case manager to identify the patient's specific needs and ensure a safe discharge. While some patients may not require any additional assistance or equipment, there are numerous instances where important issues are uncovered. For instance, it is common to find patients rationing insulin or uncertain about when they will be able to afford groceries. In such cases, it becomes the responsibility of the case manager to seek out the necessary support and services to enable these patients to lead fulfilling and prosperous lives.

This is where the rather steep learning curve comes into play for case management. For example, if you know a patient is going to need long term care, but does not have long term care insurance and does not qualify for medicaid (they make too much), how would you go about getting that person help? If the patient needs a walker or wheelchair but does not have insurance, how do you procure one for them? Are there local charities or foundations that can help? These questions get to the heart of the complexity of case management.

The normal DCP assessment is simpler than these previous examples, though. It involves a comprehensive examination of the patient's home life, aspirations, and future plans, with the aim of identifying any obstacles they may be facing. For instance, if the patient has a non-healing wound, home health services could be recommended to teach them effective wound care techniques. Similarly, if they have experienced multiple falls while using a cane, a consultation with a physical therapist or occupational therapist may reveal that they are eligible for a walker. The purpose of this assessment is to ensure that appropriate interventions are provided to address the specific deficits hindering the patient's well-being and quality of life.

The DCP plays a crucial role in case management. It acts as the backbone, connecting all the different elements together. It is like the adhesive that holds everything in place, ensuring smooth coordination and collaboration. The DCP forms the basis on which our plans are developed, working hand in hand with the patient. Together, we strive to achieve the most favorable results and outcomes. It provides a framework that supports and guides us in providing the best possible care and support. Without the DCP, the case management process would lack direction and coherence, making it difficult to deliver effective and successful interventions.