Discharge planning and case management

Question

Which statements describe an effective hospital discharge planning process? Select all that apply.

1. AThe client and the caregivers take part as active partners in planning care after discharge.✓ Correct

   Correct. The plan is built around the client’s own goals and treatment preferences, with the client and caregivers taking part in the decisions.

2. BClients likely to have problems after discharge are identified early in the hospital stay.✓ Correct

   Correct. Early identification allows evaluation and arrangements before discharge.

3. CThe plan is re-evaluated as the client’s condition changes and updated when needed.✓ Correct

   Correct. As the client’s condition shifts, the team revisits the discharge plan and revises it where needed.

4. DThe evaluation considers whether the client will need services such as home health, hospice, or community-based support.✓ Correct

   Correct. The likely need for post-hospital and non-health care services is part of the evaluation.

5. EThe unit selects one home health agency and tells the client that no other choice is available.✗ Incorrect

   The hospital may not limit the client to one agency; the client or representative must be told that other participating providers can be chosen.

6. FPlanning starts on the day of discharge so that it reflects the client’s final condition.✗ Incorrect

   Planning begins early in the hospital stay so that arrangements can be made before discharge.

Answer

A. The client and the caregivers take part as active partners in planning care after discharge. · B. Clients likely to have problems after discharge are identified early in the hospital stay. · C. The plan is re-evaluated as the client’s condition changes and updated when needed. · D. The evaluation considers whether the client will need services such as home health, hospice, or community-based support.

Rationale

Good discharge planning smooths the client’s move out of the hospital and helps prevent an avoidable readmission. It begins early for clients likely to struggle after discharge, centers on the client’s goals and treatment preferences, and brings in the client and caregivers. The team weighs likely needs for home health, hospice, extended care, and community services and revises the plan as the condition changes. The hospital may not limit the client to one provider, and it must tell the client that the choice among participating agencies is the client’s to make.