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Key Elements of IDEAL Discharge Planning Cheat Sheet (DRAFT) by [deleted]

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Introd­uction

How do you implement IDEAL Discharge Planning?
Each part of IDEAL Discharge Planning has multiple compon­ents:

Incl­ude the patient and family as full partners in the discharge planning process.
Disc­uss with the patient and family five key areas to prevent problems at home.
Educ­ate the patient and family in plain language about the patient’s condition, the discharge process, and next steps throughout the hospital stay.
Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s care to the patient and family and use teach back.
Listen to and honor the patient’s and family’s goals, prefer­ences, observ­ations, and concerns.

This process will include at least one meeting to discuss concerns and questions with the patient, family of their choice, and [identify staff].

I - Include

Include the patient and family as full partners in the discharge planning process:
Always include the patient and family in team meetings about discharge. Remember that discharge is not a one-time event but a process that takes place throughout the hospital stay.
Identify which family or friends will provide care at home and include them in conver­sat­ions.

D - Discuss

Discuss with the patient and family five key areas to prevent problems at home.
1. Describe what life at home will be like. Include the home enviro­nment, support needed, what the patient can or cannot eat, and activities to do or avoid.
2. Review medica­tio­ns. Use a reconciled medication list to discuss the purpose of each medicine, how much to take, how to take it, and potential side effects.
3. Highlight warning signs and proble­ms. Identify warning signs or potential problems. Write down the name and contact inform­ation of someone to call if there is a problem.
4. Explain test results
Explain test results to the patient and family. If test results are not available at discharge, let the patient and family know when they should get the results and identify who they should call if they have not gotten results by that date.
5. Make followup appoin­tme­nts. Offer to make followup appoin­tments for the patient. Make sure that the patient and family know what followup is needed
 

IDEAL Discharge Plan

E - Educate

Educate the patient and family in plain language about the patient’s condition, the discharge process, and next steps at every opport­unity throughout the hospital stay. Getting all the inform­ation on the day of discharge can be overwh­elming. Discharge planning should be an ongoing process throughout the stay, not a one-time event. You can:

Elicit patient and family goals at admission and note progress toward those goals each day
Involve the patient and family in bedside shift report or bedside rounds
Share a written list of medicines every morning
Go over medicines at each admini­str­ation: What it is for, how much to take, how to take it, and side effects
Encourage the patient and family to take part in care practices to support their competence and confidence in care giving at home

A - Assess

Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s care to the patient and family and use teach back.
Provide inform­ation to the patient and family in small chunks and repeat key pieces of inform­ation throughout the hospital stay
Ask the patient and family to repeat what you said back to you in their own words to be sure that you explained things well

L - Listen

Listen to and honor the patient and family’s goals, prefer­ences, observ­ations, and concerns.
Invite the patient and family to use the white board in their room to write questions or concerns
Ask open-ended questions to elicit questions and concerns.
Use Be Prepared to Go Home Checklist and Booklet to make sure the patient and family feel prepared to go home
Schedule at least one meeting specific to discharge planning with the patient and family caregivers