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Discharge Planning

Updated on January 10, 2022

Discharge planning involves completing the Discharge worksheet that records the interdisciplinary approach to the continuity of care. It is a process that includes identification, assessment, planning, and coordination. The use of the discharge worksheets help the patient, family, and care team determine what is needed to create a successful discharge plan. By completing the worksheet, organizations can mitigate re-admission risks and help provide better discharge outcomes.

The Discharge worksheet case type does not have a life cycle configured in Pega Care Management.

The available options for discharge are:

  • Home Self-Care
  • Facility/Agency/Hospice
  • Deceased

For more information about discharge planning, see the Pega Care Management Business Use Case Guide on the Pega Documentation home page.

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The following list describes items that are related to the Discharge Planning Microjourney:

  • Configuring a post-discharge care plan
  • Configuring the assessment setting for discharge plans
  • Configuring an observation period
  • Data model
  • Rules for discharge planning
  • Resolving the parent case or the child case

Configuring a post-discharge care plan

Configure a post-discharge care plan so that when you resolve a Discharge plan case for a hospitalized patient, the patient is automatically enrolled in the assigned discharge care plan.

Before you begin: Ensure that you have created the post-discharge care plan. For more information, see Creating care plan templates in Pega Care Management.
If the admission case requires a medical necessity review, the discharge worksheet is not initially added under the discharge plan in the admission case tree. The system adds the discharge worksheet at the time of the completion of the initial and concurrent reviews. Otherwise, if the admission case does not require a medical necessity review at this point, the discharge worksheet is directly added to the discharge plan in the admission case tree and provides you with the option to add a concurrent review on an ad-hoc basis.
  1. In the header of Dev Studio, click ConfigureCare Management Configuration.
  2. Click the Other settings tab.
  3. In the Post-discharge care plan field, click the assessment option that you want to use for the patient discharge.
  4. Click Save, and then click Close.

Configuring the assessment setting for discharge plans

You can select the default assessment that is used for discharge plans such as a pre-discharge assessment. When a patient is discharged, the discharge plan is automatically updated with the selected assessment.

Before you begin: Ensure that you have already created a pre-discharge assessment. For information, see Creating task templates.
  1. In the header of Dev Studio, click ConfigureCare Management Configuration
  2. Click the Other settings tab.
  3. In the Pre-Discharge Assessment list, click the assessment option to be used for patient discharge.
  4. Click Save.

Configuring an observation period

Because organizations recognize different parameters for length of stay for a patient observation in the hospital, to meet your organization's needs, you can configure the number of days for a patient observation period during an admission.

For example, based on your organization's policies, you might enter 5 days for an observation period. If you discharge the patient within the time frame of the value that you set, for example, 3 days, the Resolved-Observation status is available during case resolution. If you exceed the value that you set, for example, you discharge the patient in 6 days, the Resolved-Observation status is no longer available when resolving the case.
  1. In the header of Dev Studio, click ConfigureCare Management Configuration.
  2. On the Care Management application configuration page, click the Other settings tab.
  3. In the Observation period for admission (in days) field, enter a value.
  4. Click Save and then click Close.

Data model for Discharge Planning

In App Studio, you can view the data model for the Discharge Planning in Case types.

Click the Data model tab on the Discharge plan page.

Rules for Discharge Planning

During the Discharge worksheet case type, nurses document the discharge disposition, medications, doctor appointments, and laboratory test appointments.

Based on the needs of your organization, you can configure different sources for these options.

Key rules for discharge planning

Rule nameRule typePurpose
DischargeDispositionProperty - Prompt ListSource for the Discharge to drop-down list
Declare_CommonMedicationData pageDisplays dosage details for the old medication dose details
D_DrugCodesSearchResults Data pageFetches dosage details for the new medication based on the drug code.

Parameter is CodeSearch: NDC

D_MedicationsForDischargeData page Stores medications
DoctorAppointments Property- Pagelist Contains a list of doctor appointments
ObservationAppointmentProperty- Pagelist Contains a list of laboratory observation appointments

Field values that are available in the PegaHC-Data-Observation class are the source for the Lab test name drop-down list in the Lab test appointments section.

Resolving the parent case or the child case

You can resolve the Discharge worksheet case or the Admission case.

While resolving discharge worksheet, you can close the admission case or keep it open. You are presented with the “Do you want to resolve the admission case?” query. If you click Yes, provide the actual discharge date to resolve the admission case. Based on the response, the IsResolveAdmission flag is set. If you click Yes, the ActualDischargeDate field is visible and the admission case is resolved per the ResolveAdmissionCase activity rule. Otherwise, only the discharge worksheet is resolved.

Tags

Pega Care Management 8.7

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