IDEAL discharge planning: Smooth patient transitions from hospital to home

Written by WebMD Ignite

There are many common challenges when it comes to discharging a patient from the hospital to the home, which include adverse events and hospital readmissions. 

However, there are ways to combat these challenges by engaging patients and families in discharge planning throughout the hospital stay. To assist with this, the Agency for Healthcare Research and Quality (AHRQ) created the IDEAL Discharge Planning Implementation Handbook. The handbook is designed to engage patients and their caregivers and prevent communication gaps between patients and healthcare providers. The program is one part of a holistic evidence-based initiative to place the patient at the center of care, titled a Guide to Patient and Family Engagement in Hospital Quality and Safety.

IDEAL stands for Include, Discuss, Educate, Assess, and Listen.

Include: Make sure the patient and the patient’s family are considered partners in care and in discharge planning.

Discuss: Conversations with the patient are key so that they understand what life will be like after they transition home. Discussions should include a review of medications and test results and an explanation of what warning signs and symptoms to look out for. Follow up appointments with the patient’s healthcare providers should also be made before discharge.

Educate: Throughout the hospital stay and at discharge, patient and family education is critical in teaching self-care skills and promoting treatment adherence. 

Assess: Train and assess staff on their ability to explain health information to patients and caregivers and to use proven teaching methods such as teach-back.

Listen: It may be last in this list, but it should always be first and foremost to listen to what patients and families have to say about their needs, concerns, and goals.

AHRQ offers a full set of provider and patient materials around IDEAL discharge planning, including training materials, checklists, and patient education booklets.

Beyond IDEAL discharge planning, there are three other patient engagement strategies outlined in the Guide to Patient and Family Engagement in Hospital Quality and Safety. These include:

• Formation of patient advisory councils
• Improvement of communications between healthcare providers and patients from admission through discharge
• Explaining end-of-shift reports to patients and encouraging patient participation and nurse facilitation

Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. By partnering with patients and families, we can all make the transition from hospital to home more safe and effective.

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