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Effective discharge planning is based on a number of key principles and is an important aspect of hospital avoidance. In this written assignment (2000 words) you are required to discuss discharge planning for Kevin Johnson Part 2 from CaseWorld. Follow the structure below to guide your answer.

Describe the principles of discharge planning in relation to hospital avoidance. Describe the relevant details of the patient and current situation. Outline the key points you will make in the body of the assignment.

Explain the key aspects of an effective discharge plan for this patient and critically analyse the aspects you have identified.

Using the nursing process, discuss the activities of daily living (ADLs) that are relevant for this case at the time of discharge.

Identify the multidisciplinary team members (MDT) you, as a nurse, would refer this patient to and provide a rationale for including them in the post discharge care.

Principles of Discharge Planning in Relation to Hospital Avoidance

The principles of discharge planning in relation to that of hospital avoidance involves includes compelling release arranging needs to not exclusively be opportune (to decrease length of remain) yet additionally fuse connecting to proper follow-up consideration in the network to anticipate avoidable re-confirmations (Adam et al. 2017). The administration needs to incorporate and enhance consistence rates in GP follow-up arrangement access and participation, better people group based case administration/follow up after release, Close - to-office venture down consideration required for rural and remote patients, and also patients without satisfactory home help, following intense affirmation (e.g. non-weight bearing patients), Improve consistency of access to network doctor's facility progress benefits over all MSH offices, Improve handover to essential human services suppliers or other consideration suppliers, for example, DSQ, RACFs, NGOs, as fitting (Berry et al. 2014).

The case presented here is regarding the patient Kevin who is a 15 year old indigenous adolescent. He lives with his mother Stacey along with his four siblings. He has heightened risk of type 2 diabetes and his past medical history shows knee laceration three months ago. He also had an appendectomy three years ago. Currently Kevin is being treated for his left leg injury that has occurred as a result of a motor-bike accident.

This paper aims to bring to notice the primary aspects of an effective discharge plan for this patient presented here along with the nursing process and the activities of daily living (ADLs) along with the identification of the multidisciplinary team members (MDT) to whom this patient might be referred to.

On close evaluation of the case study it can be said that significant discharge coordination is required on account of the complex and acute nature of the medical condition as mentioned in the case study. The purpose of an effective coordination discharge planning would include requirements such as the proper maintenance of the hospital’s standard of care for the claimant and becoming familiar with the daily needs/routine of client from the hospital staff members who are continously engaged in providing care to the patient (Douglas et al. 2014). Further, the subsequent steps would involve the establishment of early claimant and family rapport with home health care providers and obtaining a critical training on DME (Dubois et al. 2013). In addition to this, a contact with the discharge planner (DCP) and the attending physician must be maintained in order to optimize the discharge orders and effectively coordinate with the authorization of the insurance company. Further, coordination with the DCP, family, home health provider and durable medical equipment (DME) suppliers to discuss claimant’s discharge treatment plan must be carried out in an efficient manner. Also, a home evaluation must be conducted to ensure DME and supplies are appropriate and safe for the accelerated recovery of the client.

Relevant Details of the Patient and Current Situation

The next step would comprise of arranging a hospital training sessions or home team training including RN, LPN /LVN and HHA. In addition to the same a formal request would be forwarded to arrange for the Home Health Case manager to meet the family, discuss treatment plan and view the claimant’s living environment (Dubois et al. 2013). The session would commence with a Q & A session for the family and time to discuss expectations. Further, immediately prior to discharge a consultation with the Physician and DCP would be arranged in order to review the discharge orders and address any last minute discharge needs.

Activities of daily living (ADLs), can be characteristically defined as the basic physical activities that help in the maintenance of a standard living. The basic ADLs comprise of activities such as grooming and maintenance of personal hygiene, dressing, managing toilet and continence, transferring/ambulating, and feeding. These basic skills are acquired early in life and are more pronounced in case of impaired cognitive functioning with an advancing age. Basic ADLs are distinctly categorized separately from Instrumental Activities of Daily Living (IADLs), which comprise of more complex activities associated with independent living within a community (e.g., managing finances and medications) (Dubois 2014). As stated by Gausvik et al. (2015), it has been mentioned that IADL performance is sensitive to early cognitive decline, compared to physical functioning which is often a significant driver of the basic ability to manage ADL.

 Physical factors such as age, sex, lesion side, cognitive function and reduced physical ability affect the designing of a discharge plan. In addition to the same, social factors such as the presence or absence of a caregiver or spouse within home environment and financial difficulties also affect the discharge plan. A lot of studies have focused on the home discharge of patients with severe injury (Gulanick and Myers 2016). The majority of patients that could manage ADL independently were discharged home with some special circumstantial exceptions. However it should be noted that although patients who required external assistance were hospitalized, there were exceptions of those who successfully completed convalescent rehabilitation. It is suggested that patients must be only discharged from facilities or hospitals after verifying the ability of the patients to manage ADL (Gulanick and Myers 2016)

In close association to the case study, it has already been mentioned that Kevin has met with an accident that has led to the fracturing of his left leg. In addition to the same, laceration in his right arm and thigh is also evident. The Orthopedic registrar has successfully done the surgery in order to align the orientation of the fractured left leg intact. In addition to the same, the lacerations in the right arm and thigh are also surgically dressed on a regular basis. Based on the same it is expected that Kevin would recover completely within 6 to 12 weeks and hence he is ready to be discharged from the hospital. The discharge plan has been considered to be extremely important in treatment process as it serves as a bridge in balancing the transition of care from a hospital setting to the home environment (Gulanick and Myers 2016). It should be critically noted that the client is a minor and still experiences sensation of pain. The immediate care providers of Kevin have been assisted to visit the plastic out-patient clinic for the removal of sutures and dressing of the lacerations after two weeks. Hence, in this context, it can be said that the client would be requiring assistance with his activities of daily living because of his persistent pain and restricted mobilizing ability. The identified areas where the client would essentially need help would include bathing, getting dressed, mobilizing and toileting and managing continence (Hibbard and Greene 2013). The left limb bone is plastered with the application of light weight casting just above the knee, in order to ensure that the bone remains undisturbed so that it can be rightly aligned.

Key Points about an Effective Discharge Plan for Kevin Johnson

The restricted mobilizing ability would be problematic for Kevin as it would impede with his ability to carry out the activities of daily living such as walking, showering, dressing and managing toilet and continence extremely difficult for him. In order to assist him with the same, it is recommended that a community helper must accompany Kevin at home until his sutures are removed. The rationale behind employing a community worker is to facilitate a healthy transition from the hospital to his home environment and at the same time assisting Kevin to comfortably manage the activities of daily living (Hibbard and Greene 2013). As Kevin has been reported to be going through is puberty, it can be assumed that he is experiencing a major physiological change in his body that is likely to make him uncomfortable with his mom or aunt helping him to manage the activities of daily living. Hence, employing a community worker would be beneficial for the client as it would help in instilling confidence in him and at the same time make him comfortable with the activities of daily living.

The multidisciplinary team members (MDT) that would be referred by me for the wellness of the patient would comprise of a community worker, a physiotherapist, a dietician, a pharmacist, and an occupational therapist. Working collectively with these multidisciplinary members would essentially help in providing a holistic care to the client and at the same time promote an accelerated recovery. As has already been discussed, the rationale behind employing a community member would essentially help in assisting the client with his activities of daily living such as bathing, dressing, walking and managing toilet and continence. It is recommended that the community worker should essentially assist the client up to two weeks till the Sutton is removed. Community nursing helpers actively engage in providing care to the patients who have restricted ability to efficiently manage ADL in a home based environment (Hill 2015). Essentially they are engaged in providing care to the elderly, minor and individuals who manage independently, however the help can be availed by anyone in need.

The rationale behind employing a physiotherapist is to administer minimal exercise to Kevin so that the recovery rate is faster and at the same time the muscles do not lose their elastic ability (Huston 2013). Studies reveal that exercising helps in improving the flexibility of the leg muscles and gradually enhance the strength and mobilizing ability (Health Quality Ontario 2013). Hence, employing a physiotherapist would essentially help Kevin gain strength through regular physical activities and it is recommended that the physiotherapy should continue up to 6 weeks after the removal of Sutton.

Activities of Daily Living (ADLs) Relevant for Kevin's Case at the Time of Discharge

A dietician has been recommended as the case study also mentions the client to be affected with a medical history of Type-II Diabetes. The dietician would essentially assist the client with a nutrition chart that would help in the maintenance of the sugar level as a rise in the blood-glucose level can cause a long term delay in the recovery of the lacerations and wound. Also, the dietician would focus on the inclusion of food items rich in calcium value so as to accelerate the rate of recovery (Lunney 2013).

The recommendation of including a pharmacist is to ensure that the client and the immediate family members are educated and made aware of the prescribed medication and the dosage as well as the intake timing. This is important as a slight deviation of the prescribed medication can elicit serious infection (James et al. 2014). Hence the pharmacist would make sure that the dose of the medicine is correctly explained to the patient as well as to his family members.

Finally, the rationale behind employing a occupational therapist is to assist Kevin acquire skills to manage his life in an independent manner. The Occupational therapist actively engage themselves with the patients to impart skills that help in enhancing the gross motor neuron activity, social skills and acquire independence in managing self-care such as dressing and washing (Fisher 2014). Occupational therapists also assist clients with sensory perceptions and impart self-management strategies to patients so that they are able to manage and gradually recover their ability to return to school or work (Fisher 2014). The OT typically makes use of strategies such as goal-setting, counseling, relaxation, problem solving and planning both in an individual as well as a group setting so as to impart proficient skills to the patients and help them in returning to normal life.


Hence to conclude, it can be said that a complete discharge care plan essentially must comprise of care elements that provide complete recovery of the patients. The care plan should be built on the basis of identification of the priority needs of the patient and must be effective to balance the transition from the hospital setting to the home environment. Also, it should be noted that the discharge plan must be chalked out in close consultation with the client as well as with the family members of the client so as to serve as a means of holistic care plan. It should further be based upon the successful long-term effects that would help the client in returning to his normal routine and should not just focus on addressing the effect of the post-operative symptoms. An effective care plan must comprise of an effective multidisciplinary team with a group of expert professionals who could cater to the wellness of the patient. For instance, in this case, the multi-disciplinary team comprised of a community helper nurse, a physiotherapist, a dietician, a pharmacist and an occupational therapist.

Multidisciplinary Team Members (MDT) to Whom Kevin Would Be Referred Post-Discharge

Each of the identified health care professionals was responsible for catering to the multidimensional health need of the client. Hence, it can be expected that the discharge plan drafted for the patient would essentially promote complete recovery of the patient within a span of 6 to 8 weeks. After the mentioned time-frame the client would be able to successfully return to his normal routine and lead an independent life.


Adam, S., Osborne, S. and Welch, J. eds., 2017. Critical care nursing: science and practice. Oxford University Press.

Berry, J.G., Blaine, K., Rogers, J., McBride, S., Schor, E., Birmingham, J., Schuster, M.A. and Feudtner, C., 2014. A framework of pediatric hospital discharge care informed by legislation, research, and practice. JAMA pediatrics, 168(10), pp.955-962.

Douglas, M.K., Rosenkoetter, M., Pacquiao, D.F., Callister, L.C., Hattar-Pollara, M., Lauderdale, J., Milstead, J., Nardi, D. and Purnell, L., 2014. Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(2), pp.109-121.

Dubois, C.A., D’Amour, D., Pomey, M.P., Girard, F. and Brault, I., 2013. Conceptualizing performance of nursing care as a prerequisite for better measurement: a systematic and interpretive review. BMC nursing, 12(1), p.7.

Fisher, A.G., 2014. Occupation-centred, occupation-based, occupation-focused: Same, same or different? Previously published in Scandinavian Journal of Occupational Therapy 2013; 20: 162–173. Scandinavian Journal of Occupational Therapy, 21(sup1), pp.96-107.

Gausvik, C., Lautar, A., Miller, L., Pallerla, H. and Schlaudecker, J., 2015. Structured nursing communication on interdisciplinary acute care teams improves perceptions of safety, efficiency, understanding of care plan and teamwork as well as job satisfaction. Journal of multidisciplinary healthcare, 8, p.33.

Gulanick, M. and Myers, J.L., 2016. Nursing Care Plans-E-Book: Nursing Diagnosis and Intervention. Elsevier Health Sciences.

Health Quality Ontario, 2013. In-home care for optimizing chronic disease management in the community: an evidence-based analysis. Ontario health technology assessment series, 13(5), p.1.

Hibbard, J.H. and Greene, J., 2013. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health affairs, 32(2), pp.207-214.

Hill, T.J., 2015. Adult Child Caregiving. In Family Caregiving in Aging Populations (pp. 39-62). Palgrave Pivot, New York.

Huston, C.J., 2013. Professional issues in nursing: Challenges and opportunities. Lippincott Williams & Wilkins.

James, S.R., Nelson, K. and Ashwill, J., 2014. Nursing care of children-E-book: principles and practice. Elsevier Health Sciences.

Lunney, M. ed., 2013. Critical thinking to achieve positive health outcomes: Nursing case studies and analyses. John Wiley & Sons.

Neuhaus, V., Swellengrebel, C.H., Bossen, J.K. and Ring, D., 2013. What are the factors influencing outcome among patients admitted to a hospital with a proximal humeral fracture?. Clinical Orthopaedics and Related Research®, 471(5), pp.1698-1706.

Schell, B.A., Gillen, G., Scaffa, M. and Cohn, E.S., 2013. Willard and Spackman's occupational therapy. Lippincott Williams & Wilkins.

Vincent, H.K., Horodyski, M., Vincent, K.R., Brisbane, S.T. and Sadasivan, K.K., 2015. Psychological distress after orthopedic trauma: prevalence in patients and implications for rehabilitation. PM&R, 7(9), pp.978-989.

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