Discharge Planning

INPAC & the INPAC Toolkit

Patients who are identified to be malnourished (SGA B or C) and who do not fully recover their nutritional status during their admission, require ongoing care in the community. Health care teams should strive to provide a referral for ongoing nutritional treatment by a dietitian when rehabilitation of nutritional status is on-going. Health care teams need to educate the patient and family on key community resources that can support access to food (e.g. meal programs) and aspects of their nutrition care plan to support continued recovery in the community.

Tips for developing a nutrition care discharge process (expand +/-)

  • Work with a team who is actively involved in discharge planning, e.g. discharge planner, social worker, hospital case manager for home care, director of nursing care, occupational therapist, physical therapist, etc.
  • Consult with other hospital health professionals to determine what they do for discharge planning. For example, occupational therapists may already be making recommendations about grocery shopping assistance or other services that can support food intake for the recovering patient.
  • Meet with local/regional outpatient dietitians in other facilities, primary care and home care to identify community resources and discuss how referrals are currently made to their service and how this can be improved.
  • Develop a list of services in your community that support food being accessible to patients; for example, meal programs (congregate dining where the patient goes to a location for the meal; meal delivery), grocery shopping and delivery, and food banks. Review this list on a yearly basis to keep it up to date. Provide phone numbers/locations and cost information.
  • Develop a flyer or handout for patient/family members on these community services as well as general recommendations to encourage adequate food intake in the community. This could also include signs and symptoms to watch out for, such as weight loss and poor appetite.
  • Discuss with your unit/hospital team how referrals can be made more consistently for patients leaving the hospital. Identify how communications can be improved (i.e., white board notes needed for referral at discharge; SGA status noted on the patient white boards; sticker on patient chart to note need for dietitian referral post discharge).
  • Educate physicians who write discharge summaries to record malnutrition as a diagnosis that was being treated in hospital. Alternatively, develop a medical directive for dietitians to chart patients' nutritional diagnosis.
  • Educate Medical Record coders on the use of the malnutrition ICD codes for these malnourished patients.


Meal and Food Support Services Documents

The following tools are provided to offer examples of patient handouts that can be provided to support continued recovery post discharge.

Physician Communication Form
This form is sent to community physicians to inform them of the nutritional status of malnourished patients.

Food is Medicine - Eating Well at Home
Food is Medicine - Eating Well for Recovery
Making sure that you get proper nutrition at home can help you recover more quickly, build and maintain muscle, prevent new illness and reduce your chances of being readmitted to the hospital.

Acknowledgment: The ideas and resources included on this page are provided in part by the hospitals involved in the More-2-Eat project.

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