Hospital discharge planning tools should incorporate the judgment of clinicians and be administratively feasible, according to a new AHA report highlighting lessons learned from five hospitals and health systems that developed innovative tools aimed at improving patient care transitions. The five tools support decision making related to when a general acute-care hospital patient should be discharged, whether a patient will need post-acute care, and what types of post-acute care may be most suitable. While their primary objectives vary, the tools have three cross-cutting themes: appropriate post-acute care placement; readmission reduction; and management of patient transitions from acute to post-acute care settings. Each of the tools was designed to align with the culture of the organization and providers using it, with a focus on reducing the burden on administrative staff and clinicians. AHA convened a technical advisory panel of members and other stakeholders to examine a variety of innovative patient discharge planning tools.

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