HYBRID EVENT: You can participate in person at Boston, Massachusetts, USA or Virtually from your home or work.

7th Edition of Nursing World Conference

October 16-18, 2023 | Boston, Massachusetts, USA

October 16 -18, 2023 | Boston, Massachusetts, USA
NWC 2023

Patricia T Michalak

Speaker at  Nursing World Conference 2023 - Patricia T Michalak
Western Carolina University, United States
Title : Multidisciplinary discharge planning to decrease hospital readmissions: An integrative literature review


Healthcare costs in the United States have steadily increased over time, reaching over $3 trillion in 2014. Medicare, Medicaid, and now the Affordable Care Act, are all programs aimed to assist patients with paying for needed services in addition to commercial insurance plans offered by employers. Yet, even with these programs in place, it is estimated that approximately 30% of the spending is attributed to unnecessary services and inefficient care delivery. The government has developed reimbursement plans aimed to decrease costs and improve care quality. Hospitals must also address these disparities to improve the quality of care they provide while decreasing the cost of care to remain financially viable. Studies suggest that 1 in 5 hospital discharges are complicated by an adverse event that can lead to subsequent emergency room visits or readmissions. Once admitted, poor planning and care coordination can lead to medication errors, increased emergency department wait times, increased costs, and other unintended negative results. Proper discharge planning can avoid these negative consequences and possibly lead to positive patient outcomes. Discharge planning should begin upon arrival at an acute care hospital when admission is deemed necessary. A standardized interdisciplinary team with a team of nurses, physicians, case managers, physical therapists, and pharmacists, can coordinate discharge planning and provide input to develop the most relevant plan for a patient.  A well-developed discharge plan benefits patients, facilities, and indirectly, future patients. Team collaboration will improve outcomes for patients, decrease overall costs for patients, and healthcare systems as well as facilitate patient flow throughout a facility. For adults 18 and over, readmission rates and length of stay decreased when an interdisciplinary team facilitates the discharge from an acute care hospital. More patients were able to return home versus another level of care which lead to increased patient satisfaction. Readmission rates and length of stay led to decreased costs for patients and hospitals. The evidence did suggest the need for greater collaboration between the inpatient and outpatient teams to better manage patient care and further decrease emergency department visits and unnecessary readmissions. The use of more than one modality to approach discharge planning was also evident in the literature, which lead to the idea of a mixed-method approach for effective and efficient discharge planning. Early involvement of a primary care provider in the discharge process showed promising results, though more research is needed. 

Audience Take Away Notes:

  • The various participants in an interdisciplinary team provide insight and experience into the plan of care.
  • The interdisciplinary team can have a positive impact on metrics such as readmission rates and length of stay.
  • The use of an interdisciplinary team for discharge planning can also affect overall costs for patients and healthcare systems, improve patient flow through the facility, and provide a better foundation for health maintenance.
  • There is a greater need for collaboration between inpatient and outpatient teams to further enhance a plan of care.


Patricia Michalak initially began her career in public service in 1999, obtaining her BS in political science. She changed gears after starting a family and earned her ADN in 2004. In 2015, she earned her BSN from Winston Salem State University while she worked as a floor nurse and then as an assistant nurse manager at Novant Health Forsyth Medical Center. In 2020, she became the nurse manager of a pulmonary progressive care unit within the same facility. She has served as chair and co-chair of multiple committees within the facility and currently serves as the chair of the nurse leadership council. In 2023, she graduated from the Master’s in Nursing Leadership program at Western Carolina University in North Carolina.