A discharge nurse is a healthcare professional who organizes and supervises patients’ discharge from the hospital. Their main job is to facilitate an optimal transition from hospitalization to the patient’s next stage of recovery, either at home, in a rehabilitation facility or elsewhere.
Reducing hospital readmissions is one of the biggest priorities of discharge nurse coordinators. Even after discharge from the hospital, patients are sometimes having trouble navigating care on their own—getting their medications, following their own self-care instructions or finding follow-up services. The discharge nurse tries to deal with these concerns by educating patients, giving them proper discharge instructions, and empathizing with the family members. They identify potential complications that patients should be aware of and help make sure they can get what they need: medication, transportation, or home health services. Discharge nurses remove obstacles to recovery and keep care in continuity, which significantly reduces the likelihood of readmission and thus leads to better outcomes and higher patient satisfaction. One of the main purposes of having a discharge nurse is to get the best care for the patient. Through personal attention to each patient’s needs and coordinated home care services (nursing, physical therapy, or physiotherapy), the discharge nurse keeps them in continuity of care. This support allows for an easier recovery, reduced complications, and better health and helps the patient move from hospital to home more easily.
Medication reconciliation is a critical function of a discharge nurse to ensure patient safety and effective post-discharge care. This process involves verifying all prescriptions, ensuring the patient understands their medication regimen, and addressing potential drug interactions or side effects. The discharge nurse provides clear instructions on the dosage, timing, and purpose of each medication, reducing confusion and the risk of errors. By facilitating proper communication between the patient, caregivers, and healthcare providers, medication reconciliation enhances adherence, prevents complications, and supports a smoother recovery process.
A discharge nurse coordinator’s support of social determinants of health is an essential part of that job description. They look at non-medical factors that might have an enormous impact on a patient’s recovery, like transportation, caregivers, and the cost of medicines or medical supplies. Identifying and overcoming these barriers also assists discharge nurses to design an integrated care plan that allows for an equitable return and lowers the risk of complications or readmissions.
Patient satisfaction is greatly enhanced when you have a dedicated discharge nurse coordinator. Patients and their families often experience apprehension and overwhelm on the hospital-to-home journey. There is a discharge nurse who offers individual attention, making sure that everything is taken care of and the care plan is clear and manageable. This focus on patients brings trust and confidence, which in turn is a feeling that patients feel appreciated and cared for. The discharge nurse helps make the overall healthcare experience better by simplifying the discharge and decreasing confusion.
It is due to regulations and cost concerns that discharge coordinators are necessary in hospitals. Hospitals are penalized through programs such as the Medicare Hospital Readmissions Reduction Program (HRRP) for a high rate of readmissions and poor discharge planning. These risks are reduced by discharge coordinators who adhere to discharge protocols and ensure the reduction of readmissions. They increase hospital performance, quality of care, and their impact on the hospital by avoiding expensive fines. Improving patient outcomes is good for the hospital’s business.
References:
Becker C, Zumbrunn S, Beck K, et al. Interventions to Improve Communication at Hospital Discharge and Rates of Readmission: A Systematic Review and Meta-analysis. JAMA Netw Open. 2021;4(8):e2119346. doi:10.1001/jamanetworkopen.2021.19346
Morkisch, N., Upegui-Arango, L. D., Cardona, M. I., Van Den Heuvel, D., Rimmele, M., Sieber, C. C., & Freiberger, E. (2020). Components of the transitional care model (TCM) to reduce readmission in geriatric patients: a systematic review. BMC Geriatrics, 20(1). https://doi.org/10.1186/s12877-020-01747-w
Pugh, J., Penney, L. S., Noël, P. H., Neller, S., Mader, M., Finley, E. P., Lanham, H. J., & Leykum, L. (2021). Evidence based processes to prevent readmissions: more is better, a ten-site observational study. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06193-x
Tyler, N., Hodkinson, A., Planner, C., Angelakis, I., Keyworth, C., Hall, A., Jones, P. P., Wright, O. G., Keers, R., Blakeman, T., & Panagioti, M. (2023). Transitional Care Interventions From Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes. JAMA Network Open, 6(11), e2344825. https://doi.org/10.1001/jamanetworkopen.2023.44825
Articles Written by:
Juram Gorriceta MPA HCM BSN RN, PMEC, LSSWBC, LSSYBH, AIPEC, CHPM
Healthcarebeyond 
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