Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning

Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. To promote stronger engagement, Agency for Healthcare Research and Quality developed the Guide to Patient and Family Engagement in Hospital Quality and Safety, a tested, evidence-based resource to help hospitals work as partners with patients and families to improve quality and safety.

Discharge from hospital to home requires the successful transfer of information from clinicians to the patient and family to reduce adverse events and prevent readmissions. Engaging patients and families in the discharge planning process helps make this transition in care safe and effective. Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning highlights the key elements of engaging the patient and family in discharge planning:

Include the patient and family as full partners in the discharge planning process

Discuss with the patient and family five key areas to prevent problems at home:

  • Describe what life at home will be like
  • Review medications
  • Highlight warning signs and problems
  • Explain test results
  • Make followup appointments

Educate the patient and family in plain language about the patient’s condition, the discharge process, and next steps at every opportunity throughout the hospital stay

Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s care to the patient and family and use teach back.

Listen to and honor the patient and family’s goals, preferences, observations, and concerns.

Strategy 4: Care Transitions from Hospital to Home: IDEAL Discharge Planning Implementation Handbook gives an overview of and rationale for the IDEAL Discharge Planning strategy and provides step-by-step guidance to help hospitals put this strategy into place and addresses common challenges.
[ Microsoft Word file Microsoft Word version - 9.9 MB ; PDF file PDF version - 545.77 KB

Word and PowerPoint files are provided so that hospitals can tailor them for their organizations. 

Tools for this strategy include --

  1. IDEAL Discharge Planning Overview, Process, and Checklist -- Handout that gives an overview of the IDEAL Discharge Planning process and includes a checklist that could be completed for each patient.
    [ Microsoft Word file Microsoft Word version - 720.52 KB ; PDF file PDF version - 188.59 KB ]
  2. Be Prepared to Go Home Checklist and Booklet
    1. Checklist highlights what the patient and family need to know before leaving the hospital and gives examples of questions they can ask. Note: The Word document uses hidden text. To see the text, go to Word Options, select Display, and choose the Hidden text box.
      [ Microsoft Word file Microsoft Word version - 1.2 MB   PDF file PDF version - 159.66 KB ]
    2. Booklet contains the checklist plus additional space for writing information. Note: The Word document uses hidden text. To see the text, go to Word Options, select Display, and choose the Hidden text box.
      [ Microsoft Word file Microsoft Word version - 511.84 KB   PDF file PDF version - 254.71 KB ]
  3. Improving Discharge Outcomes with Patients and Families -- Handout for clinicians that describes the new discharge planning process.
    [ Microsoft Word file Microsoft Word version - 689.85 KB ; PDF file PDF version - 104.82 KB ]
  4. Care Transitions from Hospital to Home: IDEAL Discharge Planning Training -- PowerPoint presentation to train clinicians and hospital staff to support the efforts of patient and family engagement related to discharge planning.
    [ Microsoft PowerPoint file Microsoft PowerPoint version - 229.13 KB ; PDF file PDF version - 218.92 KB ]

Users can download materials in zipped format by selecting: http://www.ahrq.gov/downloads/patfamilyengageguide/strategy4zipfiles.zip; 14.24 MB.

Page last reviewed June 2013
Internet Citation: Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning. June 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy4/index.html