Planning for Safe Patient Discharges (Podcast)

Care management is a vital nursing specialty that provides a bridge between hospital care and a patient’s successful return home. By ensuring that discharge plans are safe, customized and supported, these caregivers seek to reduce readmissions and promote continuity of care.

"Care managers are the heart of smooth hospital discharges," says Mark Torok, MBA, BSN, RN, CCMC, Senior Nursing Director for Care Management at Cleveland Clinic Main Campus. "They make sure every patient leaves with the right plan, the right support and the confidence to keep healing at home. It's their job to turn what could be a stressful transition into a positive, well-coordinated experience."

In the latest episode of Nurse Essentials, Torok discusses the evolving role of care managers, key components of discharge planning, the importance of evaluating a patient’s support system and home environment, and more.

Click the podcast player above to listen to the episode now, or read on for a short, edited excerpt. Check out more Nurse Essentials episodes at my.clevelandclinic.org/podcasts/nurse-essentials or wherever you get your podcasts.

Podcast excerpt

Podcast host Carol Pehotsky, DNP, RN, NEA-BC: Understanding that most patients are part of a family unit, how can care managers incorporate family feedback while also ensuring that the patient's wishes are first and foremost?

Torok: If the patient is alert and oriented, we always try to get their buy-in, but family involvement is critical to the success of any discharge, especially if the patient is going home. If a patient is new to a certain piece of medical equipment…or maybe new to tube feeding… it’s important to have a teachable caregiver [nearby]. We need somebody who’s willing to learn the process and support the patient.

And each family is different. You know, you and I might have several family members we could call for help, but a lot of people don’t. We have to assess [those dynamics] as well. What other resources are available to you? Do you have supportive neighbors? Can you drive to your follow-up appointments? There is so much variability in patients’ resources. That's why we really want to ask those questions out of the gate.

Pehotsky: How do you ensure that a discharge plan is one that the family and patient can execute successfully?

Torok: Not only do you want to review the discharge information with the patient, but you also want to go over it with the family. If you have a patient who…is [unfamiliar] with the hospital setting and what a discharge looks like, it can be overwhelming. The amount of information…the amount of people they see. So at the end of the admission and on discharge, it's important to talk to the patient and ask: Do you have any questions for me? Do you understand what level of care you're discharging to? Do you understand what a start of care looks like? We really try to get down on the patient's level so they can understand each step. A good education is pivotal.