Pathophysiology
Clinical meaning
Discharge readiness assessment is a systematic, evidence-based nursing process that evaluates a patient's physiological stability, functional capacity, knowledge, self-care ability, and support system adequacy to determine their preparedness for safe transition from the acute care hospital setting to the next level of care (home, rehabilitation facility, skilled nursing facility, or other post-acute setting). Discharge planning is not a single event occurring on the day of discharge but a continuous process that begins at admission and evolves throughout the hospital stay. Poor discharge preparation is a leading contributor to preventable hospital readmissions, with approximately 20% of Medicare patients readmitted within 30 days and an estimated 27% of those readmissions being potentially preventable with better discharge processes. The Hospital Readmissions Reduction Program (HRRP), established by the Affordable Care Act in 2012, imposes financial penalties on hospitals with excess readmission rates for specific conditions (heart failure, acute myocardial infarction, pneumonia, COPD, total hip/knee arthroplasty, and coronary artery bypass graft), creating significant institutional motivation to improve discharge processes. The conceptual framework for discharge readiness encompasses four domains that nursing assessment must address. The first...