1. COMMUNICATION
ESSENTIALS:
Interdisciplinary Discharge
Planning

2. NURSING CORE COMPETENCIES:
FOR INTERDISCIPLINARY DISCHARGE PLANNING
Communication
 “The Nurse of the Future will interact effectively with patients,
families, and colleagues, fostering mutual respect and shared
decision making to enhance patient satisfaction and health
outcomes” (Masters, 2014, p.78).
Teamwork
 “The Nurse of the Future will function effectively within nursing
and interdisciplinary teams, fostering open communication,
mutual respect, shared decision making, team learning, and
development” (Masters, 2014, p.78)

3. WHAT IS COMMUNICATION?
 A process that includes 5 factors:
 SENDER – encodes a message to be transmitted;
 MESSAGE – the ideas, symbols, signals being transmitted;
 CHANNEL/MEDIUM – the means by which a message travels;
 RECEIVER – receives and decodes the message; and
 FEEDBACK – Receiver provides feedback to Sender to signal
effective reception of intended message (Oxford University
Press, 2014; Communication Models and Theories, n.d.).

4. COMMUNICATION:
PROCESS CYCLE
Sender
Message
Chanel/MediumReceiver
Feedback
(Oxford University
Press,2014).

5. NURSE-PATIENT
COMMUNICATION:
SUCCESSFUL INTERACTION
 Scenario: During Admission Intake, Nurse Hope Soeiltry would like to
obtain a medication list from Patient Will U. Listinclose for a safe medication
reconciliation.
 Sender (Nurse: Hope) – encodes her message with words by asking a question
 Message (The Question) – what medications do you take at home? Can you tell
me and write them down on this paper to include the name, dose, and time you
take them?
 Channel/Medium (Verbal/Written) – both verbal and written responses
 Receiver (Patient Will) – decodes the message; begins to tell Nurse Hope his
medications from home while writing them down
 Feedback (Patient: Will) - asks if he should write down his over-the-counter
medications while showing Nurse Hope his medication list in progress. Nurse
Hope nods in agreement while saying, “absolutely correct!”.
 Outcome of Communication: SUCCESS!

6. EFFECTIVE COMMUNICATION:
BARRIERS TO SUCCESS
 Noise or Interference – ambient noise, alarms, bells, televisions,
radios;
 Medium chosen poorly – incompatible language, incompatible
medium i.e. hearing impaired (chose verbal transmission), visually
impaired or illiterate (chose written transmission);
 Message – unclear, inappropriate, incongruent, lacks context;
 Receiver – emotionally/psychologically compromised (angry,
anxious, sad, fearful, uncooperative/unreceptive); physically
compromised (pain, fatigue, altered mental status);
 Feedback – Receiver did not provide feedback to ensure
successful communication occurred; Sender did not request for
feedback (Communication Models and Theories, n.d.).

7. STRATEGIES TO OVERCOME
BARRIERS:
EFFECTIVE COMMUNICATION
 Sender – is clear, concise, and congruent during message
transmission process;
 Reduce or Eliminate – sources of interference with a calm, quiet,
and timely delivery environment for the communication to take
place;
 Select Appropriate Medium – relative to the age, ethnic/cultural,
and language determined to be compatible with the receiver;
 Assess the Receiver – for readiness i.e. Alert, oriented, well
rested, with a reasonable mood disposition; and
 Request Feedback – ask the receiver is they understood the
message delivered; exercise a repeat-back and verify process to
ensure successful delivery.

8. DISCHARGE PLANNING AND
EFFECTIVE COMMUNICATION: WHAT &
WHEN
Definition:
 “Preparation for moving a patient from one level of care to
another within or outside the current health care agency”
(Bulechek, Butcher, Dochterman, & Wagner, 2013, p.150).
When:
 “Planning for discharge begins during the initial contact with
the client by establishing the expected outcomes and
anticipating follow-up care that may be needed”
(Harkreader, 2007, p.206).

9. DISCHARGE PLANNING AND
EFFECTIVE COMMUNICATION:
RATIONALES
Poor Planning and Discharge Communication is Costly:
 “Poor communication can endanger patients’ lives and waste
fiscal and human resources” (Lattimer, 2011).
 “Delays, omissions, and inaccuracy of discharge information are
common at hospital discharge and put patients at risk for adverse
outcomes” (Harlan, 2010).
 “It’s often poor communication, coupled with an expectation that
patients or caregivers will remember and relate critical
information, which can lead to dangerous, even life-threatening,
situations” (Lattimer, 2011).

10. RN DISCHARGE ACTIVITIES:
OVERVIEW
NURSING INTERVENTIONS CLASSIFICATION (NIC) SUMMARY
 Assist patient/family/significant others to prepare for discharge;
 Collaborate with interdisciplinary team/patient/family/significant
others;
 Coordinate with other providers for a timely discharge;
 Identify patient / caregiver knowledge or skills required for
discharge;
 Identify patient teaching required for post-discharge care;
 Communicate patient discharge plans as appropriate;
 Monitor readiness for discharge;
 Formulate discharge maintenance plan;
 Arrange post-discharge evaluation; and
 Discharge to next level of care (Bulechek et al., 2013 p.150).

11. CASE MANAGEMENT: OVERVIEW
DISCHARGE ACTIVITIES
 Screening and Intake – identify discharge disposition / placement and
destination;
 Assess needs – financial resources, treatment plans coordinated with
physician, patient and family for smooth discharge transitions;
 Service planning – initiate plan of care, identify barriers to outcomes
achievement, post-discharge service need identification, setting mutual goals
with family/patient;
 Link patient to what they need – resource utilization, appropriate length of
stay planning, evaluation of expected outcomes progress;
 Implement Interdisciplinary Treatment Plan – monitor expected outcomes,
begin arranging post-discharge arrangements, re-evaluate discharge
destination if needed; and
 Evaluate Patient Care Outcomes – based on plan of care progress towards
achieving outcomes; round with the attending physician to obtain progress
feedback (Cesta, 2013).

12. DISCHARGE COMMUNICATION:
INTERDISCIPLINARY STRATEGIES
 Team Approach:
 Discharge Planning Teams (Rose & Haugen, 2010).
 Standardizing Communication:
 “S-B-A-R” (Bengasco et al., 2013).
 Evidence-Based Discharge Education:
 “Teach-Back” (Kornburger et al., 2013).

13. DISCHARGE PLANNING TEAMS:
MULTIDISCIPLINARY INTERVENTION
STUDY
 Based on a study conducted in a Progressive Care Unit (PCU) in a
Midwestern Hospital (Rose & Haugen, 2010):
 Problem – Current Discharge Process Concerns
 Incomplete / Inaccurate Discharge Summaries
 Incomplete Prescriptions
 Inconsistent Discharge Education
 Communication Gaps regarding: Discharge dates, time, and disposition
 Intervention – Formation of Discharge Planning Teams
 Possible Outcomes – Effective Discharge Planning
 Decreases Re-admissions
 Promotes Cost-effective Use of Inpatient Beds
 Increased Patient / Staff Satisfaction

14. DISCHARGE PLANNING TEAMS:
IDENTIFYING KEY MEMBERS
 Physician,
 Physician Assistant (P.A.),
 Nurse Manager,
 Registered Nurse,
 Pharmacist,
 Social Worker,
 Discharge Planner,
 Secretary, and
 Continuous Improvement Specialist (Rose &
Haugen, 2010).

15. DISCHARGE PLANNING TEAMS:
ACTIVITIES PER DISCIPLINE
 Physician & P.A.:
 Education on pathology and surgical reports,
 Writes discharge prescriptions the night before discharge, and
 Completion of discharge summaries;
 Registered Nurse:
 Education on post-discharge care requirements night before
discharge and on the day, and
 Coordinate follow up for outstanding discharge items to be
completed;
 Pharmacist:
 Fills prescriptions at Hospital Outpatient Pharmacy; and
 Verifies insurance information as soon as possible to fill script
promptly (Rose & Haugen, 2010).

16. DISCHARGE PLANNING TEAMS:
JOINT ACTIVITIES –SURVEY, AUDIT &
RESULTS
 Pre-implementation of Discharge Planning Teams:
 Discharge Summaries – 60% completion rate,
 Prescriptions Written – 45% completed night before discharge,
 Nursing Staff Satisfaction – 37% contentment with discharge process, and
 Patient Satisfaction – 93% perceived a smooth process;
 Post-implementation of Discharge Planning Teams:
 Discharge Summaries – 91% completion rate by 2007,
 Prescriptions Written – 88% completed night before discharge by 2007,
 Nursing Staff Satisfaction – 91% contentment with discharge process by
2007, and
 Patient Satisfaction – 100% perceived a smooth process by 2007 (Rose &
Haugen, 2010).

17. DISCHARGE PLANNING TEAMS:
KEYS TO SUCCESSFUL
IMPLEMENTATION
 Communication Remains Open – Across all disciplines
must be open to facilitate acceptance of changes in processes;
 Multidisciplinary Involvement – input from various
disciplines facilitated the efficiency of workflow by identifying
barriers related to other departments/services; and
 Continuous Improvement Process – teams must be
cognizant of the changes in health care environment: Payer
systems, regulatory agencies, and processes, ready to adapt to
changing conditions (Rose & Haugen, 2010).

18. STANDARDIZING COMMUNICATION:
RATIONALES FOR IMPLEMENTATION
 Good Communication is characterized by:
 Timeliness,
 Standardization of Content, and
 Well coordinated between disciplines (Reilly, Marcotte, Berns, & Shea,
2013).
 Errors in Communication results in:
 Adverse Events with Negative Patient Outcomes,
 Negative Emotional Impacts for Patients & Caregivers,
 Increased associated Costs,
 Increased Length of Hospital Stay,
 Loss of Patient Trust, and
 Increased Risk for Litigation (Bagnasco et al., 2013; Reilly et al., 2013).

19. STANDARDIZED COMMUNICATION:
PROPOSED METHODS
 S.B.A.R – Situation, Background, Assessment, &
Recommendations:
 Recommended as a Standardized Communication Tool, and
 Has Written and Verbal components for Communication at Patient
Hand-off and Transfer (Bagnasco et at., 2013).
 Proposed Benefits – S.B.A.R Implementation:
 Mitigation of Risk associated with poor Communication during Patient
Hand-off and Transfer i.e. Memory Failures,
 Standardizes Communication Styles of various healthcare workers to
create uniformity, and
 Optimizes communication timing via Standardized reporting
procedure (Bagnasco et al., 2013).

20. DISCHARGE EDUCATION:
EVIDENCE-BASED STRATEGIES
 “Teach-Back” Process – “a comprehensive, interdisciplinary, evidence-
based strategy which can empower nursing staff to verify understanding,
correct inaccurate information, and reinforce medication teaching and
new home care skills with patients and families” (Kornburger et al., 2013).
 Proposed Benefits – “Teach-Back”: Implementation
 Provides opportunity to Verify Understanding, Correct Inaccurate Information,
and Reinforce Medication Education and Home Care Skills;
 Valuable, Easily Implemented and Understood, and Cost-effective Education
Strategy;
 Engages Patients and Families in learning activities;
 Patient and Family-centered Education Strategy (Kornburger et al., 2013).

21. DISCHARGE EDUCATION:
TEACH-BACK PROCESS
 “Teach-Back” Goal – Effective Family / Patient Self-Management:
 Step 1: Teach a New Concept or Skill,
 Step 2: Clarify or Correct Misunderstandings,
 Step 3: Acknowledge any Questions Patient/Family may Have, and
 Step 4: Continue the Process until Concept or Skill is Understood (Kornburger
et al., 2013).
 Nurse Competencies – Understand Health Literacy Principles:
 Encourage Patient/Family Questions,
 Use Plain Language,
 Limit Teaching to 3-5 Concepts, and
 Document “Teach-Back” education in the approved form (Kornburger et al.,
2013).

22. SUMMARY & CONCLUSION
 Communication Highlights:
 Is a vital function to ensure Patient Safety;
 Failures occur mostly during points of Transfer of Care;
 Failures carry a significant potential for Adverse Patient Events;
 Standardized Communication methods optimize outcomes;
 Discharge Planning Highlights:
 Requires an Integrated, Multidisciplinary & Team Approach;
 Begins at Admission, is ongoing, and is constantly re-evaluative in nature;
 Is Patient and Family-centered; anticipating needs constantly;
 Requires effective communication between patients, family, and Healthcare
Team; and
 Requires pre-emptive, evidence-based discharge Education from entire team
(Bagnasco et al., 2013; Kornburger et al., 2013; Reilly et al., 2013; Rose &
Haugen, 2010).

23. REFERENCES
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24. REFERENCES
Kornburger, C., Gibson, C., Sadowski, S., Maletta, K., & Klingbeil, C. (2013). Using
“Teach-Back” to Promote a Safe Transition From Hospital to Home: An
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