X. Discharging Patients

A. General Considerations

1. Planning ahead
   
   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. 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 Geriatrics NP or to the Long Call resident.
   
   
2. 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].
   
   
3. The role of the NP
   
   Work closely with the NP to ensure that all the action items necessary to facilitate the discharge are addressed/completed early in the morning (or prepared the day before). These action items may include forms for medical transportation, home health, and equipment that must be attested/signed before discharge. The NP will assist you so that the discharge order can be written before 10:00 AM and your patient can leave in a timely manner thereafter.
   
   
4. Pharmacist
   
   Page the Geriatrics pharmacist once the discharge orders are reviewed and are pended. The pharmacist who is available M-F, must review the medication orders for medication reconciliation, before the discharge orders are signed.
   
   
5. Discharge Summary
   
   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

1. 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.
   
   
2. 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 SNF or 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.
   
   
3. If the patient has 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 available resources.
   
   
4. Identify home health needs, such as home PT, OT, RN, MSW, bath aide, IV antibiotic therapy, blood work, equipment such as walkers, braces, O2, nebulizers, new urinary catheter, etc. 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.
   
   
5. 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.
   
   

C. Discharging Patients to the SNF

1. Utilize the Discharge To Facility Navigator (see Appendix B) to create the Interfacility Order (IFO). Follow the Skilled Nursing Facility (SNF) Discharge Checklist and Guidance below.
   
   
2. Print the IFO and review the printout with the attending to ascertain that the printed details are an accurate and complete reflection of the initial orders to be followed upon admission to the SNF (please note the SNF physician has up to 72 hours to see the patient).
3. Please forward the IFO document (or if applicable, the revised printout) to the NP for final review and placement in the Discharge Packet by the unit secretary. Only the reviewed and final paper copy of the IFO must be sent to the SNF.
   
   
4. Please provide handoff to the accepting SNF physician; check with the case manager for the name and contact information of the accepting SNF MD. (You may also refer to amion for accepting MDs in UCLA-staffed SNFs).

D. Keys To A Smooth, Well-Orchestrated Handoff

1. Complete Interfacility Order (IFO): The IFO serves as the SNF Admission Orders when the patient arrives at the SNF. No IFO, no SNF admission. If revised, final copy must be sent with patient; discard old one. 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.
2. Discharge Summary: must include pending tests results that need to be followed-up by MD (e.g. urine culture, path report).
3. Signout to the accepting SNF MD: Send by email with an FYI alpha page notifying of the discharge to SNF (method preferred by UCLA SNF Geriatricians and SNF Hospitalists).

E. Things to Keep in Mind When Planning SNF Discharge

1. 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.
2. SNF MD:  generally not on site at the time patient arrives; has up to 72 hours to see the patient.
3. 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