A hospital discharge service is necessary to make the transition from hospital to home or a rehabilitation centre easier and less stressful.

The discharge plan can be compiled by a social worker or nurse once the patient has received authorisation from the physician.

Discharge planning will include the following:

  • Qualified personnel will have to evaluate the patient;
  • A discussion should be held with the patient or representative;
  • The return home or the transfer to another facility should be planned;
  • Must be ascertained whether the patient required a caregiver or any other support;
  • Homecare agencies or appropriate support agencies need to receive referrals;
  • Follow-up appointments or tests need to be arranged.

A discussion should take place to determine the specific needs of the patient.  It should include detailed information of the patient’s medication prior to hospitalization, as well as new medication.  The patient’s diet should be discussed e.g. the patient may be diabetic or suffering from high cholesterol.  The appropriate diet should then be planned.  One should also determine whether equipment such as walking aid, wheelchair or equipment is needed.  Decisions also have to be made regarding me3al preparation, chores and means of transport from the hospital.

For a suitable discharge plan to be drawn up it must include input from the patient (if possible), family, the care manager, the physician, nurse, social worker, therapists and the insurer.

Transitional Care can be improved by following a few simple steps.  For example, the patient’s family doctor should receive a detailed summary of care – this will result in more effective follow-up care.  Phone calls from professionals to the patient being discharged.  By taking these few simple steps it will help to anticipate problems as well as improving care at home of the patient.

Several factors have to be taken into account before it is deemed safe for a patient to be discharged from the hospital to be returned home or to another non-acute environment.

These factors are the following:

  • The cognitive status of the patient;
  • The level of activity and functional status of the patient;
  • Whether there is the support of family or companion support;
  • Whether the patient is able to obtain medication and service;
  • Whether the patient has transport home and to the follow-up visits;
  • The availability of community services that can assist the patient with ongoing care.


Patients who are discharged must be able to do the following themselves or with the help of a caregiver / family:

  • To be able to obtain their medication and self-administer their medication;
  • Able to care for themselves;
  • Follow an appropriate diet;
  • Follow-up visits to physician, therapist etc.

The acceptance of the patient with regards to the respective facility is also a requirement.  If the patient is not in favour of a specific facility, then another appropriate facility must be found.

A number of patients who get discharged are re-admitted to the hospital a couple of days later. 

There are several factors that can lead to re-admission.

  • Being discharged prematurely or the post-discharge support is inadequate;
  • Follow-ups are insufficient;
  • There are therapeutic mistakes;
  • Hand-offs that have failed;
  • Complications that arise as a result of procedures;
  • Infections occur, a patient falls or the appearance of pressure ulcers.

Medication errors are the most common reasons for re-admission.  Almost 2/3 of these re-admissions can be prevented.  These errors are normally caused by the following:

  • Patients are not provided with the prescriptions for the necessary medication;
  • Duplicate prescriptions are given to patients. In other words, patients have the same medication at home but under a generic name;
  • Inadequate follow-ups and the monitoring of side effects caused by drugs.

To prevent such errors, there must be direct communication between hospital and the aftercare provider.


Broader recommended changes in practice and policy are needed.  They are:

  • Formally recognise the role families and other unpaid caregivers play. Include them as part of the healthcare team and access their capabilities and willingness to provide care;
  • Co-ordinate care across sites, from hospital to facility to home. Improve communication between hospital and community-based services;
  • Develop better educational materials, available in multiple languages, to help patients and caregivers navigate systems. They will also then be better able to understand the type of assistance that might be available to them, both during and after a hospital stay;
  • Improve training for healthcare staff, including ways to respond to language, culture and literacy differences;
  • Simplify and expand eligibility for public programmes;
  • Change re-imbursement policies to cover more home-based care in addition to institutional care.

Reward hospitals and physicians that improve the wellbeing of the patient and reduce patient re-admissions to hospitals []

Good discharge planning is essential today because patients are being discharged far earlier than in the past.  It is therefore crucial that these people receive excellent care once discharged.

According to studies, 40 percent of patients older than 65 make errors while taking medication and have to be re-admitted within 60 days.  This is a very costly exercise which can be prevented with effective planning.  Effective hospital discharge is a service which makes the transition from hospital to home or a care facility much less stressful.  This effective planning will also result in lowering the re-hospitalisation rates which is also cost effective.


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