Evaluation of the Implementation of Discharge Planning in Patients with Diabetes Mellitus in Hospitals and Its Improvement Strategies

Abstract

Discharge planning is an important part of hospital services that aim to ensure the sustainability of patient care after discharge, especially for patients with chronic diseases such as Diabetes Mellitus (DM). However, the implementation of discharge planning at dr. Soekardjo Tasikmalaya Hospital has not been running optimally, characterized by the absence of a standard Standard Operating Procedure (SOP) or SOP that is not applied consistently. This study aims to evaluate the implementation of discharge planning in DM patients, identify the obstacles faced, and formulate evidence-based improvement strategies. This study uses an evaluative descriptive approach with a qualitative method. Data was collected through observation, in-depth interviews with seven informants (health workers and patients), and review of medical record documents. SDSCA and RHDS instruments are used in a limited way to support field findings. The results showed that discharge planning was only carried out at the oral education stage before the patient discharged, without written planning, multidisciplinary team involvement, or evaluation of patient readiness. Patient self-care and readiness scores are relatively low, and most health workers state that they do not have a standard reference in its implementation. The absence of SOPs is the main obstacle that causes the implementation of discharge planning to be unstructured and undocumented. As an improvement strategy, it is recommended to prepare evidence-based SOPs, establish a multidisciplinary discharge planner team, and implement continuous education with post-graduation monitoring. This strategy is expected to improve the quality of discharge planning services and outcomes for DM patients.