What discharge instructions should be provided to a patient being transferred to a skilled nursing facility (SNF)?

Comprehensive Discharge Instructions for Patients Transitioning to Skilled Nursing Facilities

Discharge planning should begin at hospital admission, with clear diabetes management instructions and comprehensive transition documentation provided at discharge to ensure safe and effective care transitions to skilled nursing facilities. 1

Essential Components of Discharge Documentation

Medical Information

• Document the patient's complete diagnosis list, including diabetes type clearly identified in the medical record 1
• Include recent vital signs, laboratory results (especially HbA1c if available), and pending tests 2
• Provide information on recent procedures, treatments, and current clinical status 2
• Document target parameters for blood pressure, heart rate, glucose levels, and weight 1

Medication Management

• Perform thorough medication reconciliation to ensure no chronic medications are stopped and to verify safety of new prescriptions 1
• Cross-check home and hospital medications, documenting any changes with clear rationale 1
• For patients with diabetes, specify the insulin regimen (basal, nutritional, correction components) and target glucose ranges (generally 140-180 mg/dL) 1
• Include information about medication sensitivities, adverse reactions, and titration plans 1

Follow-up Care

• Schedule follow-up appointments prior to discharge, as this enhances appointment-keeping behavior 1
• For patients with diabetes, schedule an outpatient follow-up visit within 1 month of discharge (or within 1-2 weeks if medications were changed or glucose management is not optimal) 1
• Clearly identify healthcare providers who will manage specific conditions (e.g., primary care, cardiology, endocrinology) 1

Communication with SNF

• Transmit discharge summaries to the SNF as soon as possible after discharge 1
• Provide structured discharge communication that includes pending tests, follow-up needs, and changes in clinical status 1
• Document risk for rehospitalization and strategies to mitigate this risk 1

Disease-Specific Instructions

Diabetes Management

• Include specific glucose monitoring protocols and target ranges (generally 140-180 mg/dL for non-critically ill patients) 1
• Document hypoglycemia management protocol and prevention plan 1
• Provide instructions for transitioning from IV to subcutaneous insulin if applicable 1
• Include consistent carbohydrate meal plans to facilitate matching prandial insulin to carbohydrate intake 1

Heart Failure Management

• Document signs and symptoms of fluid retention that SNF staff should monitor (edema, abnormal lung sounds, dyspnea, orthopnea, jugular vein distension) 1
• Include target weight and instructions for proper weighing procedures (same time daily, after voiding, same clothes) 1
• Provide guidance on when to notify healthcare providers about weight gain, edema, or shortness of breath 1
• Document information about implantable devices (pacemakers, ICDs) including device settings and deactivation preferences if applicable 1

Patient and Caregiver Education

Self-Management Education

• Provide "survival skills" education focused on essential information needed for safe care 1
• Document the patient's level of understanding regarding their diagnosis, monitoring, and when to call healthcare providers 1
• Include education on recognition, treatment, and prevention of hyperglycemia and hypoglycemia 1
• Assess need for home health referral or outpatient education programs as part of discharge planning 1

Caregiver Involvement

• Identify appropriate caregivers to participate in educational sessions, especially for patients with cognitive or sensory impairments 1
• Assess patient and caregiver ability to learn and manage treatment regimens 1
• Document family's understanding of the care plan and their involvement 1

Special Considerations

Cognitive Assessment

• Document cognitive status using standardized tools (e.g., Brief Interview for Mental Status from MDS 3.0) 1
• For patients with cognitive impairment, ensure caregiver education and involvement in discharge planning 1
• Consider health literacy and sensory impairments when developing educational materials 1

End-of-Life Planning

• Document advance care preferences, including resuscitation status and hospital transfer preferences 1
• For patients with defibrillators, include preferences regarding deactivation as part of advance care planning 1
• Consider palliative approaches to symptom management while maintaining appropriate disease management 1

Implementation Strategies

Structured Discharge Process

• Use a standardized checklist approach to ensure all discharge elements are completed 3
• Begin discharge planning on the day of admission and continue throughout hospitalization 3
• Consider post-discharge clinic interventions which have been shown to reduce 30-day rehospitalizations and emergency department visits 4

Medication List Optimization

• Generate electronic medication lists that include both brand and generic medication names 5
• Provide accurate indications for medications in layperson terms 5
• Create patient-specific discharge medication lists that consider age, vision, and health literacy 5

By implementing these comprehensive discharge instructions, healthcare providers can facilitate safer transitions from hospitals to skilled nursing facilities, potentially reducing readmissions and improving patient outcomes 6, 4.