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Discharge Planning

Inadequate discharge planning can often result in poor outcomes and increased likelihood of hospital readmissions for children with special health care needs. Faced with limited discharge options, health care professionals may feel they have no choice but to send children home to families and communities that may not be able to provide the necessary care in a safe environment. Too often the discharge date is set by the guidelines of the family's insurance or by the clinical status of the child. Outcomes would be improved if the discharge date included an assessment of the readiness of the family's home care plan in addition to the health care status of the child.

The Center for Infants and Children with Special Needs at Cincinnati Children's Hospital Medical Center provides information and resources to help families and health care professionals improve the discharge planning process.

Hospital to Home | Additional Resources

Hospital to Home

Discharge from a hospital does not necessarily mean that your child is fully recovered. It simply means that a physician has determined that your child's condition is stable and hospital-level care is not currently required. Because you will continue to play a primary role in your child's home care, you and your health care team should consider all the supports you will need. Help may include nursing, therapy, home modifications, transportation, financial assistance, emotional support and management of other needed services. The family and health care team should take steps to help improve home care success:

Parent Notebook to keep track of all the therapies, physicians, health care orders and other resources is vital to an organized transition from hospital to home
Social Assessment Form to record important child and family information
Discharge Planning Form for information to assist the child returning home from the hospital
A proper discharge should include:

Training of family caregivers
Applying for eligible government progams and financial assistance
Setting up private duty nurses and outpatient therapies
Arranging for necessary equipment and supplies including durable medical equipment, such as a wheelchair
Investigating safe and adequate transportation and housing
Finding resources for needed home modifications
Communicating with school and work about necessary accommodations

Insurers often cover home care services that are not specifically identified in the benefit plan if it can be shown that the child can go home sooner and is less likely to be readmitted. Speaking to your employer's benefits or human resources department can also help if a needed benefit is not covered, especially if the employer is self-insured.

Providing general information about the specific conditions the child has and making sure it is available to caregivers as well as the family usually helps everyone anticipate and understand the various medical, developmental and/or behavioral situations that may occur.

If a child has a potentially life threatening condition, local emergency medical services (EMS) and utilities should be notified of the patient's condition to ensure that they are familiar with the medical needs and priority in the event of an emergency.

The number of families who speak languages other than English is increasing. The health care team should plan ahead to request the services of an interpreter, when needed, to assist with assessing family needs and translating important patient information and resources.