Module 3: Summary: Expected Outcomes
- DA aware of discharge order and completes Patient Care Plan
- Medication list
- Pending tests and results
- Post-discharge services
- PCP identified
- Follow-up appointments made
- DA conducts final teaching and teach-back with patient and family
- Post-discharge followup occurs
- Transmit summary and Patient Care Plan to PCP
- Phone patient within 48 to 72 hours
- Measurement of discharge process complete
- Plans for teaching frontline staff finalized
In Module 3, we reviewed the activities that occur once the discharge order is written. After completing this module, you should ensure your structure and processes facilitate the DA’s completing and teaching the Patient Care Plan. In addition, you should finalize processes for post-discharge communication with the PCP and patient and review how measurement will take place.
Once you complete the activities associated with Modules 1 through 3 and have your final plans in place, you should train the staff who will be working with the DA and the targeted patient group. A sample presentation on Project RED implementation that you can adapt for your organization is available on this Web site.
You may also want to hold a general information session with other hospital staff or consider a brief article about this project for your hospital’s newsletter or Intranet.