Planning a Safe Discharge Home From a SNF So Residents Don't Bounce Back

A discharge home is the goal for most short-stay residents. It is also a risky moment. The resident leaves a building with nurses around the clock and goes back to a home where a spouse, an adult child, or the resident alone is now in charge of medications, meals, mobility and appointments.

When something in that handoff is missed, the result can be a return trip to the hospital within days. Most of the fixes depend on starting early and being thorough.

Start Discharge Planning at Admission

Federal rules expect discharge planning to begin early and continue through the stay. Under 42 CFR 483.21(c)(1), each facility must have an effective discharge planning process that focuses on the resident's discharge goals, prepares residents to be "active partners," and reduces factors that lead to preventable readmissions. The process must:

• Identify each resident's discharge needs and develop a discharge plan
• Re-evaluate the resident regularly and update the plan as needs change
• Involve the interdisciplinary team
• Consider whether caregivers are available and able to provide the care needed
• Involve the resident and representative, and address their goals of care and treatment preferences

In practice, the first care plan meeting is a good time to ask: Where will this person go home to? Who will help? What will they need to do there that they cannot do yet?

Teach the Caregiver, Then Check With Teach-Back

Families often get a large amount of information on discharge day, when they are tired and distracted. Teaching works better when it is spread across the stay and when staff confirm understanding.

AHRQ's Re-Engineered Discharge (RED) Toolkit, built for hospitals but useful as a model, recommends the teach-back method. The person explains the information back in their own words. If they cannot, the staff member re-teaches and asks again. AHRQ stresses that teach-back tests how well staff explained it, not the patient's knowledge, and should be used with everyone.

Good topics for teach-back include:

• Which medications changed, and why
• Warning signs that mean "call the doctor" versus "call 9-1-1"
• How to help with transfers, walking or equipment safely
• Who to call with questions after hours

Hand Off the Medication List Clearly

Medications deserve special attention. Under 42 CFR 483.21(c)(2), the discharge summary must include a reconciliation of all pre-discharge medications with the resident's post-discharge medications, both prescription and over-the-counter.

Make sure the resident and caregiver leave with one clear, current list. Encourage them to bring all their home pill bottles to a final teaching session so old prescriptions that were stopped or changed can be identified. Any questions about what to take belong with the prescribing provider or pharmacist, not guesswork at the kitchen table.

Line Up Follow-Up, Home Health and Equipment

The same regulation requires a post-discharge plan of care that states where the resident will live, any arrangements for follow-up care, and needed medical and non-medical services. The RED toolkit lists organizing post-discharge equipment and at-home services and following up on pending test results among its core steps.

Before discharge day, confirm:

• A follow-up appointment with the primary care provider or specialist, with date, time and transportation
• Home health referral accepted and the start-of-care date known, if ordered
• Durable medical equipment delivered or scheduled, such as a walker, shower chair or oxygen
• Any pending lab or test results assigned to a provider to follow up
• The discharge summary sent to the next provider

If the resident is going to another post-acute provider, 483.21(c)(1) also requires the facility to help the resident and representative choose one, using relevant quality and resource-use data.

Make a Phone Call After Discharge

The RED toolkit recommends a follow-up phone call 2 to 3 days after discharge. The call reviews health status, medications, appointments, home services and equipment, and what to do if a problem comes up. AHRQ notes the medication review is usually the longest part of the call.

A short scripted call from a nurse or social worker can catch a missed prescription, a home health visit that never happened, or a new symptom while there is still time to call the provider.

Why It Shows Up in Your Quality Data

CMS's SNF Quality Reporting Program includes a claims-based Discharge to Community measure. It looks at how often Medicare beneficiaries are discharged to the community after a SNF stay, remain alive, and have no unplanned hospital or long-term care hospital readmission within 31 days of discharge. The program also includes a Potentially Preventable 30-Day Post-Discharge Readmission measure and Transfer of Health Information measures.

What to Do This Week

• Pick two current short-stay residents and confirm each has a written discharge plan that names the caregiver.
• Add teach-back to at least one family teaching session per discharge.
• Check that discharge medication lists are reconciled and reviewed with the caregiver in person.
• Make a simple checklist for appointments, home health, equipment and pending results.
• Start post-discharge calls at 2 to 3 days, even for a small group, and track what you find.

Keystone's monthly reports can help leaders see patterns in returns to the hospital so discharge processes can be refined over time.

This article is general education for skilled nursing teams. Follow your facility's policies and the direction of your medical director and providers.