Factors that need to be considered in discharge planning that have been identified in previous projects include:
- Ensuring that discharge arrangements are discussed with patients, family members and carers; and that they are given a copy of the discharge summary.
- Adequate coordination between the hospital, community health services, general practices, and the providers of social care services.
- There is a follow-up after discharge of patients at high risk of complications or readmission – either in person or by telephone – to ensure that the discharge arrangements are working well.
- Medicines reconciliation is carried out. This is the process of verifying patient medication lists at a point-of-care transition, such as hospital discharge, to identify which medications have been added, discontinued, or changed from pre-admission medication lists.
- Ensuring that any outstanding test results at discharge are obtained and passed on to primary care teams; and ensuring there are clear arrangements for carrying out and acting on any proposed post-discharge tests. In general, dealing with tests results is the responsibility of the clinical team that carried out the test.
- Give patients clear instructions about any post-discharge tests that are needed and how these will be carried out.
- Ensure that hospitals comply with the National NHS Standard Contract – for example, issuing Fit Notes for the expected duration of sick leave and supplying patients with an adequate amount of medication.
A useful summary of previous work on discharge planning (mainly based on US studies) can be viewed in UpToDate.