What is IDEAL Discharge Planning in Home Health?

The discharge process can be a fragile time for patients. Nearly 20% of patients have adverse events within three weeks of discharge from care, of which roughly three-quarters can be prevented. One of the most significant issues is poor transition in care. Implementing IDEAL discharge planning at the time of discharge may help improve the changeover, lower unplanned readmissions, and improve health outcomes. 

What Is IDEAL Discharge Planning?

Discharge planning is the steps involved in moving a patient from one level of care to the next. A successful patient discharge involves patient education and information transfer between healthcare providers. 

To facilitate better outcomes, the Agency for Healthcare Research and Quality (AHRQ) created the IDEAL discharge planning framework. IDEAL acts as a discharge guide to help providers engage patients and families during a release from the hospital or other care. 

The IDEAL discharge planning overview process and checklist are as follows:

  • Include patients and family caregivers as partners in the discharge process.
  • Discuss five areas to prevent problems at home.
    • What to expect
    • Medications
    • Warning signs
    • Test results
    • Follow-up appointments
  • Educate the patient about their condition, the discharge process, and the next steps.
  • Assess how well doctors and nurses explain the above and use teach-back.
  • Listen and honor the patient’s goals, concerns, and preferences.

Benefits of IDEAL Discharge Planning in Home Health

Patients may receive a medical discharge from the hospital but still require at-home care or monitoring of medical conditions. Physicians may order home health care as part of the continuity of care and to ensure positive outcomes. 

Eventually, you will also discharge patients from home health. The IDEAL discharge planner is a beneficial tool to facilitate the process. It first evaluates patients and confirms that outpatient providers are no longer necessary. Then, it prepares patients and families for daily living without medical care or support. 

This preparation is likely the greatest benefit. Patients and families receive the necessary information that helps them live independently and manage their health, which leads to positive outcomes. A systematic review of research shows that effective discharge planning reduces hospital readmission, decreases the length of a hospital stay, and improves patient satisfaction with the quality of care. 

How to Implement IDEAL Discharge Planning in Home Health

The first step in implementation is to evaluate your current discharge planning process and identify areas of improvement. Assess your existing policies, family visitation meetings, documentation management, and the outcomes your patients experience with your current system. Then, set goals. 

Once your goals are in place, decide how to adapt the IDEAL checklist into your practice. Ensure educational materials and discharge instructions use plain language for patients and families. Data shows that long and complex information confuses patients and leads to noncompliance. 

Next, create a phased implementation plan, beginning with staff training. Set a start date and continually assess the process during the first month. Collect feedback from patients, families, and staff and refine procedures to address problem areas. 

The Future of IDEAL Discharge Planning in Home Health

The AHRQ created the IDEAL discharge planner to help providers build partnerships with patients when discharged from the hospital. Home health agencies can adopt this process to develop similar benefits and improve patient outcomes. 

Managing documents and communication between clinicians is essential for a smooth process. Modern automated document platforms like WorldView streamline updates and communication for better patient care. Learn how to simplify your operations with WorldView.  Schedule a demo.

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