X3.7 Discharge planning
Involving the patient’s general practitioner in a case conference and developing a care plan may facilitate early discharge
Discharge planning involves the patient, external lay and professional carers, the multidisciplinary hospital and community team and the patient’s regular GP. It should commence on admission and be documented within 24–48 hours (see Box 12). Appropriate patient education and attention to preventive management are likely to reduce the frequency of further acute exacerbations. Assessment of social supports and domestic arrangements are critical in discharge planning. Medicare items support aspects of discharge planning. See http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdiseasemanagement-qanda
A discharge pack, which includes general information about COPD, advice on medication use and written instructions on use of inhalation and oxygen devices, if appropriate, as well as a plan for management of worsening symptoms, should be provided. The GP (and respiratory outreach program, if available) should be notified during the patient’s admission. A case conference involving the multidisciplinary team and GP may assist successful transition to the community. Medicare Benefits Schedule Enhanced Primary Care item numbers may be claimed for “participation in a case conference” and “contribution to a care plan” (see section D).
Before discharge, referral to a comprehensive pulmonary rehabilitation program should be considered.
Suggested criteria for a patient’s readiness for discharge include:
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COPD-X Plan - Version 2.34 - November 2012