A. General Considerations
The key to a well-coordinated and timely discharge is advance planning. As mentioned earlier, the anticipated discharge date is best communicated to the patient and their family in advance so appropriate plans for the day of discharge are made, including the availability of family or responsible party (if applicable) and the means of transportation. Other care needs including necessary equipment and home health should be identified ahead of time and conveyed to the case manager; caregiver needs and non-medical transportation needs are to be conveyed to the social worker; needs for patient/family/caregiver training for home tasks like new Foley care, wound care must be conveyed to the nursing staff (home health nurses are generally not available for daily home visits). If the patient is to be discharged to a SNF, prepare and pend the Interfacility Order and the Discharge Summary the day prior and then update and finalize on the day of discharge.
If the patient requires ambulance transportation upon discharge, please identify this in advance and inform the case manager. Ambulance transport services require Code Status orders. You may complete the Code Status Order form (available at the 5NW front desk) OR a copy of the POLST form (please make sure the POLST copy reflects the most up to date code status); please be sure to provide either document to the unit secretary (5NW and off floor, if applicable) in a timely manner and definitely before you leave for the day if the patient is leaving late. Please do NOT delegate this to the Night Float.
Timing of Discharge Orders
The goal is to write the discharge order before 10:00 AM, whenever it is possible. This helps ensure that we will have available beds for waiting patients and that our patients who are discharged to the SNF will arrive at the facility in a timely manner. As mentioned, your attending will see the planned discharges prior to the 9:00 AM rounds so the discharge order can be written, pended/signed before 10:00 AM. Please make sure all discharge-related processes are addressed and completed before finalizing the DC orders [e.g. Interfacility Order (IFO) and Discharge Summary for patients being discharged to the SNF].
Call the Geriatrics Pharmacist at x98512 (available 8:00AM-4:00PM, Mon-Fri) as soon as the discharge orders are reviewed and are pended. The pharmacist reviews the medication orders for medication reconciliation, before the discharge orders are signed.
Patients who are discharged to the SNFs should have their prepared discharge summaries updated, signed and be available for printing at the time of discharge. Patients who are to be discharged home should have their updated discharge summary signed and available for viewing within 48 hours. Late discharge summaries result in poor continuity and may lead to suspension of physicians' admitting privileges.
B. Discharging Patients Home
Consider in advance who is available to provide the necessary help at home (e.g., family member, caregiver), if the patient is unable to perform self-care activities (ADLs) such as getting in and out of bed, toileting, etc., or, if he or she needs assistance with instrumental activities of daily living (IADLs) such as medication management, cooking, etc. If the patient has a decline in his or her ability to ambulate or in his or her ADL function, and if he or she may benefit from a rehab stay at a Skilled Nursing Facility (SNF) or Acute Rehab Facility (ARU), please consult PT/OT early to assist in determining a more appropriate next level of care for the patient, prior to eventually returning home.
- Identify home health needs early, such as home PT, OT, RN, MSW, bath aide, IV antibiotic therapy, blood work, durable medical equipments (DME) such as walkers, braces, O2, nebulizers, suction machine etc. Please note that home O2 orders take at least 24 hours (can be longer) to arrange so please order supplemental O2 early, complete the attestation promptly (see above to access SmartPhrase template) and inform the clinical case manager; it is easier to cancel the O2 order if the patient does not end up needing it, than to order for it to be delivered on the same day (nearly impossible!)
- Place home health orders and attestation as soon as anticipated so they can be tasked promptly. Present the patient's anticipated home health needs to the Clinical Case Manager during the IDR as soon these are identified before the day of discharge. Some DMEs are covered by insurance, however an order and attestation of medical necessity is required and must be documented in the progress note. Additional home health tasks added after the initial order was placed (e.g. labs to be drawn by home health) must be added to the home health order AND specifically conveyed to the clinical case manager of the day.
Social Work Services
- If the patient has ADL/IADL needs and it is unclear to you who is able to assist the patient at home, present the situation to the Social Worker during IDR, so that she may assist the patient in exploring the patient’s support system. The Social Worker also assists in exploring caregiver resources including In Home Support Services (must have MediCal to qualify), alternative residential sites of care such as assisted living facilities (ALF) and board and care facilities (B&C) and if appropriate, longterm nursing home placement.
- If the patient requires non-medical transport for the planned day of discharge, please request the SW to assist in arranging this.
PCP and Specialist Follow-ups
- Upon discharge, please request follow-up appointments for patients to be seen by PCP within 7-10 days, and if indicated, by specialist services within the recommended time frame.
- If the patient is on warfarin, identify the provider who will monitor the INR. If warfarin therapy was newly started during the patient's hospitalization, enroll the patient in the Anticoagulation Management Service (AMS), by generating a referral unless the provider does not utilize the services of the AMS. If the patient was already on warfarin therapy prior to hospitalization, monitoring is generally to be resumed by the appropriate provider or service; please consider that this may be an outside cardiologist and not the PMD.
- Discharge Summary must include pending tests results that need to be followed-up by MD.
Geriatrics Pharmacist Services
- Prior to entering DC orders on weekdays, pend medications and contact the Geri Pharmacist (x98512; available on weekdays) to review pended meds. For anticipated weekend discharges, try to pend meds on Friday for the Geri pharmacist to review.
- New anticoagulation with DOACs and expensive medications may require prior authorization. Get the process started early. Notify our Geri pharmacist for assistance as soon as you know a patient will require this upon discharge. Send medication to 16th street for price check.
- Please check with Geriatrics Pharmacist regarding Meds to Bed delivery option, if the patient has way to pay at bedside. Note that the 16th street pharmacy is only open on weekdays (8am-6pm) and Saturdays (8am-5pm). It is CLOSED on Sunday; this is important to note because medications e-prescribed to this pharmacy are difficult to cancel on Sundays and risk not getting covered by insurance when ordered to an alternative pharmacy without successful cancellation of the previous prescriptions.
C. Discharging Patients to the Skilled Nursing Facility (SNF) and Acute Rehab Facility (ARU)
Notify clinical case manager as soon as the need is identified. If there is a decline in the patient’s ability to ambulate or in his or her ADL function, the patient may benefit from a rehab stay at a Skilled Nursing Facility (SNF) or Acute Rehab Facility (ARU), please consult PT/OT early to assist in determining a more appropriate next level of care for the patient, prior to eventually returning home. SNFs generally require PT assessment and documentation of recommendation prior to accepting the patient (generally, OT assessment and documentation of recommendation is required in addition to PT for patients going to ARU).
If you think the patient may qualify for an ambulance (e.g, unstageable or stage 4 pressure injuries, managed care patients, or if in doubt), contact case manager. All other forms of transportation, including non-emergency gurney transport, wheelchair van, uber, etc, contact SW.
If the patient is DNR, complete a POLST form or Ambulance Code Form if the patient is discharging to a facility (forms can be obtained from the Unit Secretary) via ambulance; please do not defer this task to your co-resident or Night Float.
The InterFacility Order (Click here for How to Create the Interfacility Order)
This is a crucial document that must be included in the Discharge Packet for all patients who are being discharged to the SNF or ARU, because it serves as the SNF Admission Orders when the patient arrives at the SNF. No IFO, no SNF admission.
- Must be prepared and pended the day before SNF discharge.
- Utilize the Discharge To Facility Navigator on Care Connect to create the Interfacility Order (IFO). Follow the Skilled Nursing Facility (SNF) Discharge Checklist and Guidance below.
- Print the IFO and review the printout with the Attending to ascertain that the printed details are the orders to be followed upon admission to the SNF (please note the SNF physician has up to 72 hours to see the patient). Please ensure that the orders are accurate and complete.
- Please forward the reviewed IFO printout to the unit secretary for placement in the patient’s Discharge Packet. Only the reviewed and final paper copy of the IFO must be sent to the SNF. If orders are revised on care connect, only the final printed copy must be sent with patient; remove the old one from the Discharge Packet. Keep in mind that the accepting physician is not on site when the patient is admitted at the SNF. SNF nurses do not carry out orders if they are written only in the DC summary.
- Medications and Discharge Orders Checklist
Note: Prior to entering DC orders on weekdays, pend medications and contact the Geri Pharmacist (x98512; available on weekdays) to review pended meds. For anticipated weekend discharges, try to pend meds on Friday for the Geri pharmacist to review.
SNFs utilize their own contracted pharmacies which are located off-site. Administer time-sensitive meds (e.g. IV antibiotics, pain meds, blood pressure meds) prior to hospital discharge (there is always a several-hour medication delay because meds cannot be requested until patient arrives. Click No Print for medication orders so they are not routed the patient’s usual pharmacy, except for controlled substances (click Normal) and dispense a 5 day supply.
- Special meds (e.g., oral chemo, erythropoiesis-stimulating agents, IV antibiotics) already confirmed by case manager
- Antibiotics has both diagnosis and stop date indicated. Enter info in note to pharmacy as text (under class)
- Anticoagulant includes diagnosis (and, if warfarin, the target INR range). Enter info as above
- Antihypertensives and chronotropics include holding parameters
- If on sliding scale insulin, sliding scale details are written (sliding scales are not templated at SNF)
- If on psychotropics, informed consent has been documented in the discharge summary
- Medications administered via G tube in strictly NPO patients are carefully ordered as such
- Routes for pain medications are oral, transdermal, or suppository (IV pain meds are unavailable at the SNFs). Note that ALL scheduled drugs must electronically prescribed to the contracted SNF pharmacy (see posted Pharmacy information for Geri-SNFs in the IDR room)
- Bowel regimen is included, routine or PRN. If routine, please add to hold for loose stools.
- Pharmacologic DVT prophylaxis is continued if indicated during hospitalization; the SNF provider will decide when to dc
- Respiratory treatment orders are feasible (unrealistic to expect suctioning >2 x/day or nebulizers >3x/day)
- Weight bearing instruction is indicated in the IFO for pts with orthopedic injury/surgery
- Code status is written (If there is a POLST, most up to date POLST is included in discharge packet; instruct unit secretary)
- Diet specifies consistency of solids and liquids if other than regular. If poor oral intake, consider liberalizing diet and fluid intake
- Labs: if following hemoglobin, electrolytes, creatinine, or drug levels, a plan for follow-up has been made. When entering order, indicate date expected. For class and resulting agency, select external. (If closer follow up than within 72 hours is needed, must sign out to accepting SNF provider). If on warfarin, must include next PT/INR date and target INR
- CPAPs and BiPAPs settings are ordered; if pt does not own one, inform case manager to ensure SNF or ARU will provide
- Wound vacs & other special equipment have been cleared with the case manager
- Follow-up appointments have been requested in the IFO (appointments that are necessary and time-sensitive. Do not request for PCP follow-up; it will be handled by the SNF team upon discharge from SNF.
- PT, OT, and Speech Therapy ordered as appropriate
- All other nursing orders must be written here (e.g. PVR checks, intermittent urinary catheterization, wound care etc.)
- For patients who need feeding assistance, add “RNA feeding assistance with meals” in nursing communication
- Please request only necessary specialist follow-up appointments and necessary follow-up imaging studies. There is no need to request PCP follow-up appointments will be arranged by the SNFist upon discharge from SNF.
- Common DMEs such as walkers, commodes, hospital beds, O2 will be provided by the SNF while the patient is at the SNF; if deemed to be necessary upon eventual discharge from the SNF, the SNFist is responsible for ordering these for home use. Braces (e.g. TLSOs, neck braces), AFOs, hinged knee immobilizers are generally not provided at the SNF and must be ordered from Orthotics and Prosthetics prior to discharge.
- Discharge Summary
Discharge summaries of patients who are to be discharged to the SNF should be prepared the day before their discharge, and are to be finalized and available for printing on the day of discharge. Discharge summaries created in advance are to be updated and refreshed to reflect final changes on the day of discharge, including changes to the discharge medications.
Must include pending tests results that need to be followed-up by MD (e.g. urine culture, path report).
- Signout to the accepting SNF MD
Please provide a brief handoff to the accepting SNF physician highlighting follow-up needs; check with the clinical case manager for the name and contact information of the accepting SNF MD. UCLA GeriSNFists and HospitalistSNFists prefer email signouts.
- Keys To A Smooth, Well-Orchestrated Handoff
- Complete and Accurate Interfacility Order (IFO):
Discharge Summary: must include pending tests results that need to be followed-up by MD (e.g. urine culture, path report).
Send by email with notifying of the discharge to SNF (method preferred by UCLA SNF Geriatricians and SNF Hospitalists).
- Complete and Accurate Interfacility Order (IFO):
- Things to Keep in Mind When Planning SNF Discharge
- Timing is everything: discharges should occur as early as possible for many reasons, the paramount ones are to avoid missed medications and minimize patient confusion due to change of location at night.
- SNF MD: generally not on site at the time patient arrives; has up to 72 hours to see the patient.
Nursing:RN: SNFs with < 99 beds are required to have 1 RN during the day shift (8 hours); SNFs with >99 beds are required to have 1 RN each shift. Therefore, orders that require an RN for administration, such as IV pain meds, are generally impractical in the SNF.
LVN: administers all oral, SC & nebulized meds. Ratio varies from 1 LVN per ~25-30 patients.
CNA: assists with feeding, toileting, dressing, etc. Ratio varies from 1 CNA to ~7-13 patients
D. Discharging Patients to Assisted Living Facility (ALF) and Board and Care (B&F)
- Inform Social Worker
- Returning patients: Some facilities may require their staff to come & assess the patient prior to transfer back, may require completion of a new Physician’s Report/RCFE or 602 form (please check with SW; click here to view form), and may require Covid testing within a certain time frame prior to discharge. Some ALFs help arrange transit back to the facility. New admissions to ALF require TB clearance (negative CXR or neg PPD or neg Quant TB gold (please check with SW what test is acceptable).
- New ALFs/B&C: in addition to above, will generally always need a Physician’s Report/RCFE or 602 form.