The Enhanced Discharge Planning Program Eases a Patient's Transition Home

Article excerpt

In this model, medication management is just one hurdle crossed to a successful transition home.

The Enhanced Discharge Planning Program (EDPP) at Rush University Medical Center in Chicago, Illinois, is an evidence-based transitions model that was developed to improve health outcomes for older adults. The program serves approximately 1,200 people annually.

In 2007, two groups, Older Adult Programs and the Case Management Department, created the EDPP program as a joint project. Social workers with master's degrees coordinate care services and use a holistic approach to assess the post-discharge care plan. Particular attention is paid to assessing medication management, caregiver burden and ability to cope with care demands, and follow-up appointments. Interventions are by phone and are initiated within forty-eight hours after patient discharge.

Each day, a Risk Report from the patient's electronic medical record (which includes notes on items such as re-admission within six months; insurance barriers; primary diagnosis and problem list; history of heart failure; number of medications; high-risk medications; learning barriers; falls risk; pain score; diagnosis of depression; psychosocial needs; and disposition of home with home health) and interdisciplinary rounds that include EDPP social workers generate referrals to the EDPP. The assessment of risk factors is the crucial starting point for the definition of risk; this is used as a tool, in conjunction with the interdisciplinary team discussion, to decide who should be followed by EDPP after discharge.

Fostering collaborative relationships between healthcare and community providers encourages problem solving and self-management. Typically, both medical and communitybased services providers involved in the post discharge situation operate in silos (minimal communication and connection to one another), which hinders the ability to provide continuity of care and effective problem solving that lead to better outcomes. EDPP interventions are able to connect providers with each other around the patient and caregiver as the focus of care. The culture of care becomes more collaborative (and efficient) as providers work together to solve problems and promote patient self-management.

The EDPP model has four phases: referral, pre-assessment, assessment, and intervention. The average duration of an intervention is five days. The transition from hospital to home is considered stable once all providers are connected and any new service referrals are com- plete. The following case is an example of the model in action, and how it was used to address medication issues.

Referral: A Patient May Need Enhanced Services

Anita, age 67, was admitted to the hospital with shortness of breath, and reported being less able to take care of herself over the previous several months. During interdisciplinary rounds, the team discussed her history of alcohol abuse (Anita acknowledged using alcohol for a long period of time, but denied that it was a problem), heart disease, and liver problems. The nurses reported she was slightly unsteady when walking and needed some assistance with personal care.

The discharge planner met with Anita, who reported that she lived with her husband and had a supportive family. However, she expressed concern that her husband had health problems, making it hard for him to help her. Physical and occupational therapists saw Anita at the hospital and recommended she go home with follow-up therapy. The interdisciplinary team agreed home health visits would be beneficial and Anita should be referred to the EDPP program for post-discharge intervention. A referral was made to a home health agency for nursing, and physical and occupational therapies. The discharge planner also referred her to the local department of aging for homemaker services. Anita reported getting her medications filled at a local pharmacy, and there were no medication needs identified by the team before discharge. …