Discharge planning is the process of identifying and preparing for a patient’s anticipated health care needs after they have transitioned from the hospital to home. It is a process that involves the engagement of the Anthem HealthKeepers Plus member (your patient), family, and health care team. If done correctly, effective discharge planning improves patient safety, patient quality and cost outcomes.


Statistical data


Health disparities are known to contribute to readmission risks. Medicaid readmissions are considered significant; therefore, they can be widespread and costly. Statistical data is shown below:


  • Medicaid all-cause 30-day readmission rates for patients ages 21 to 44 (19.2%) and 45 to 64 (21.6%) are higher than Medicare readmission rates (17.3%).


  • Nearly 20% of members experience an adverse event within three weeks of discharge.


  • Three quarters of adverse events could have been prevented with proper discharge planning.


  • The most common complications post-discharge include adverse drug events, hospital acquired infections and procedural complications.


  • Nearly 20% of Medicare patients were re-hospitalized within 30 days after discharge.


  • Approximately 70% of surgical patients were re-hospitalized with a medical problem.


  • The cost of unplanned hospitalization in 2004 was $17.4 billion.




Under the Affordable Care Act, there are certain hospital readmissions that could lead to a penalty and cause lower reimbursements. In 2012, there were more than 2,000 hospitals penalized related to preventable readmissions. This specific mandate has caused the need to focus in on patient-centered care and a discharge plan that is all-inclusive. Discharge planning can be a complex process; however, having safe transitions from the hospital to home is a top priority. The IDEAL discharge planning strategy seeks to engage the patient and family in the discharge planning process. Building effective relationships with the member and family will ensure patient quality and patient safety. Embracing a culture of open communication will optimally lead to positive patient outcomes and help to make the transition to home safe and effective. 


The IDEAL Discharge Planning strategy


There are many ways to promote effective discharge planning. This article focuses on the IDEAL Discharge Planning Strategy. The IDEAL Discharge Planning strategy is a strategic way to engage the patient and family in the discharge planning process. Its focus is on a culture of inclusivity:


  • Include the patient and the family in the complete discharge planning process. This is a process that carries on throughout the entire hospitalization. Determine who will provide care for the patient at home and be sure to include this individual in the team meetings and conversations.


  • Discuss with the patient and family five areas to prevent problems when they return home. These five areas include home life, medication reconciliation, potential warning signs and concerns, test results with thorough instructions, and follow-up appointments with providers.


  • Educate the patient and family in layman terms about his/her condition and the discharge process. Complete education throughout the entire hospital stay. Address patient and family goals at admission and throughout the hospital stay.


  • Assess how well the information has been provided to the patient by the doctors, nurses and other health care professionals and use the teach-back method to ensure understanding. Avoid overloading the member with too much information.


  • Listen to and respect the patient and family’s goals, preferences, observations and concerns. Use motivational interviewing such as open-ended questions to spark questions and concerns. Schedule a meeting prior to discharge with patient, family, and interdisciplinary team.


Challenges to discharge planning:


  • Fragmented care due to multiple providers and inability to keep scheduled appointments.


  • Medication reconciliation discrepancy (complex or high-risk medications).


  • Inadequate discharge preparation.


  • Miscommunication between provider, patient and family.


  • Communication and education not properly completed.


  • Information or educational offerings not provided in layman terms.


  • Appropriate teachings based on how the patient best learns not utilized (verbal, audiovisual).

  • Inability to have patient self-manage his/her condition.


Evidence-based practices to improve discharge planning:


  • Come up with your own discharge planning sheets or checklists and follow them per your facility policies and procedures.


  • Provide trainings on effective discharge planning with nursing staff and allow staff to feel a part of the process.


  • Empower patients through educational activities throughout the stay to help them better understand their conditions, manage their diet, manage activities, manage medications, manage care regimens and manage follow-up care.


  • Provide attention to discharge planning on the first day of admission and throughout the entire stay, providing a multidisciplinary approach.


  • Develop a plan for care coordination after discharge and complete any follow-up appointments prior to the patient leaving the facility.


  • Always implement practices or set aims to improve discharge planning in your facility.




Agency for Healthcare Research and Quality (2017, December). Strategy 4: Care transitions

from hospital to home: IDEAL discharge planning. Retrieved from https://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy4/index.html


Barrett, M.L., Weir, L.M., Jiang J. H., Steiner, C.A. (2015). Cup statistical brief #199: All-cause readmissions by payer and age, 2009–2013. AHRQ Healthcare Cost and Utilization Project. Retrieved from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb199-Readmissions-Payer-Age.pdf. Accessed April 13, 2020.


Torrey, T. (2020). Discharges and readmissions. Verywell health. Information about ACA

Hospital Discharges and Readmissions. Retrieved from https://www.verywellhealth.com/affordable-care-act-hospitals-2614805



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September 2020 Anthem Provider News - Virginia