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This is a three page paper on change project. The paper has assessed the need for change in discharge planning by identifying the problem that requires change to improve it. It has explored the literature regarding the change and identified the transition theory as the most appropriate in the implementation of change. A reengineered discharge plan for change has been designed in order to enhance the effectiveness of discharge planning. It is in APA format with ten sources.

Assessment of the need for change

Proper hospital discharge can result in significant improvements in the health of the patients while at the same time reducing the rates of readmission. Patients are extremely vulnerable after discharge from the health care facility as they usually experience medical errors. It is estimated that one out of every five hospitalizations are usually complicated by the adverse events that occur soon after the patients are discharged from the health care facility (Wong et al, 2011). There are approximately 32 million Americans who are discharged from the health care facilities across the country every year and the deficiencies in discharge planning have resulted in unnecessary use of hospital services, increased costs and illnesses (Kripalani et al, 2007). Most of the procedures for discharge planning in the health care facility are not standardized with most of the discharge summaries lacking important data. This has resulted in a situation where the clinicians lack awareness regarding the pending test results of the patients during discharge (Jack et al, 2009).

In most of the health care facilities, there is lack of standardization regarding the process of discharge planning. Health care systems also lack adequate systems support for ensuring the transfer of data to the caregivers (Moore et al, 2003). Discharge summaries play an important role in the care of patients after discharge but they only provide limited information. In addition, they are not provided at the required time and this presents a challenge in the provision of care to the patients in the period following discharge (Kriplani et al, 2007). Most of the patients usually lack appropriate discharge preparation as they have a limited understanding when it comes to their medication and diagnoses (Makaryus and Friedman, 2005).

Evidence for change

According to Walker et al (2007), the discharge of patients without the fulfillment of their needs increases the health related complications as well as the risk of readmission. Understanding the needs of the patient at the time of discharge is important in achieving positive outcomes. Coleman (2006) argues that discharge planning plays a crucial role in ensuring that patients continue with their recuperation and attain their normal functioning. Proper discharge planning can reduce the rates of hospital utilization within 30 days following the discharge of the patient from the health care facility. A reengineered discharge plan has a number of elements that are crucial in effective discharge planning. There are a number of studies that have been carried out in order to demonstrate the effectiveness of the reengineered discharge plan in the process of discharge planning. Jack et al (2009) reported that there were reduced rates of hospital utilization within 30 days after discharge following the implementation of the reengineered discharge plan for reducing hospitalizations. Jack and Bickmore (2008) showed that there was a reduction in the rate of hospital utilization in the group that used the reengineered discharge plan when compared to those in usual care within 30 days of discharge. Greenwald and Jack (2009) reported that the reengineered discharge plan was effective in reducing the rate of re-hospitalization for those patients that were high users of hospital services and was cost effective. The various studies demonstrate the efficacy of the reengineered discharge planning in supporting seamless transition of care from hospital to home care settings. A reengineered discharge plan can go a long way in reducing the rates of hospitalization and the costs of hospitalization.

Appropriate change theory

The most appropriate theory for ensuring effective discharge planning is the transition theory developed by Meleis. This theory details the process of transition as a passage from one phase of life to another during which the change in the health status creates a period of vulnerability. According to this theory, the nature of the transition in the therapeutic processes will determine whether the outcomes will be positive or negative for the patients (Meleis et al, 2009). Design of the re-engineered discharge plan for discharge planning

There are a number of steps that the health care facility will follow in designing a reengineered discharge plan for reducing hospitalizations. All the medical records of the patients will be reviewed in order to obtain significant information that is required for effective discharge planning as well as transition of care. A discharge advocate will organize a meeting between the patients and the caregivers 24 hours after admission and orient them to the reengineered discharge process and its role in supporting effective care transition. All the essential information for designing the reengineered discharge plan will be collected and recorded in the discharge workbook. Appointments for tests as well as follow up will be drafted in order to ensure ongoing care to the patients in the period after discharge. The discharge advocate will also organize for outpatient services and medical equipment that are required by the patient after discharge. All the medications that need to be taken by the patient after discharge will be identified and planned for. The discharge plan will be reconciled with the national guidelines in order to establish any possible discrepancies. An assessment of the patients level of understanding regarding the reengineered discharge plan will be carried out. Patients will be informed on how they can consult their physicians after discharge. Clinical information will be transmitted from the hospitals to the caregivers in the post discharge environment. Telephones will be used to reinforce certain aspects of the reengineered discharge plan at home (Jack et al, 2009).


Coleman, E.A. (2003). Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51: 549-555.

Greenwald, J.L., and Jack, B.W. (2009). Preventing the preventable. Professional Case Management, 14(3): 135 – 142

Jack, B., & Bickmore, T. (2009). The reengineered hospital discharge program to decrease hospitalization. Retrieved from http://www.bu.edu/fammed/projectred/publications/RED%20Fact%20Sheet%202-7-09%20v2.pdf

Jack, B., Greenwald, J., Forsythe, S., O’Donnell, J., Johnson, A., Schipellti, L., Goodwin, M., et al (2009). Developing the tools to administer a comprehensive hospital discharge program: The reengineered discharge (RED) program. Bookshelf ID: NBK43688PMID: 21249944

Kripalani, S., Jackson, A. T., Schnipper, J. L. and Coleman, E. A. (2007). Promoting effective transitions of care at hospital care: a review of key issues for hospitalists. Journal of Hospital Medicine, 2:314–323.

Makaryus, A.,& Friedman, A.(2005).Patients’ understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc., 80,991-4

Meleis, A.L., Sawyer, L.M., Im, E.O., Hilfinger Messias, D.K., & Schumacher, K. (2000). Experiencing transitions: an emerging middle-range theory. Advances in Nursing Science, 23(1): 12 -28.

Moore, C., Wisnivesky, J., Williams, S., & McGinn, T. (2003). Medical errors related to discontinuity of care from an inpatient to an outpatient setting. Journal of General Internal Medicine, 18,646-51

Walker, C., Hogstel, M. O., & Curry, L. C. (2007). Hospital discharge of older adults. American Journal of Nursing, 107(6), 60-70.\ Wong,E., Yam,C., Cheung,A., Leung,M., Chan,F., Wong,F., & Yeoh,E.(2011). Barriers to effective discharge planning: a qualitative study investigating the perspectives of frontline healthcare professionals. BMC Health Services Research, 11,1-10.

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