CMS moves to empower patients to be more active participants in the discharge planning process. 2014 May;22(5):63-6. Case managers are directly involved in discharge planning and thus have direct accountability regarding readmissions; therefore, they must refine the admission assessment screening to include specific information based on a patient's preadmission level of care. Transitional planning as a process CMS’s transitional care management services Case management transitions Role of RN case manager and social work case manager in discharge planning The admission assessment role in the discharge plan Triggers for social work consults in complex discharge planning A Sample of Private-Sector Hospital Discharge Tools Case studies of hospital discharge planning tools that strive to improve transitions to post-acute care and reduce readmissions. IDEAL Discharge Planning Overview, Process, and Checklist -- Handout that gives an overview of the IDEAL Discharge Planning process and includes a checklist that could be completed for each patient. The Donald W. Reynolds Foundation Care Management Services Michael Wang, M.D. Discharge Summary (Form) Discharge or Transfer if there is inadequate planning. Case management nurses, as with discharge planners, work collaboratively with the healthcare team to meet the needs of the patient. Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube. Case Management Skills Checklist. In addition, the case management plan of care you develop identifies outcomes that are measurable and achievable within a manageable time frame and that apply evidenced-based standards and care guidelines. Collaborates with Case Management Medical Director, Director, and/or Manager on complex discharge planning issues and delays in service. B. “ Case Management ” means a collaborative process of assessment, planning, facilitation, care coordination, … • INSPIRED 2.0 invites and engages the client in the planning for and understanding of their disease (Patient -Focused) – Care Providers: Case-Managers, Respiratory Educators and other Interdisciplinary Team members as required. Cesta T. Hand-off communication provides an important link for patients and care providers as patients transition across the continuum of care. Policy 9.1.14 Patient Discharge Planning 11/01/92 -Originated 06/10/05 -Reviewed w/ changes 04/11/03 -Reviewed w/o changes Nursing Service -Author _____ Page 3 of 6 Roles in Discharge Planning, continued Care management: If the patient is unable, ensure the patient’s family/caregiver has been contacted as necessary to inform them of the • Care Components match the COPD Discharge Bundle – Data elements complement discharge bundle data by adding some Physician Lead Discharge Planning Checklist UC Irvine Healthcare case managers, clinical social workers and physician teams will: 1. Case Study on IDEAL Discharge Planning: Advocate Trinity Hospital ----- 22 References ----- 24. “Nursing typically has delegated anything to do with discharge planning to the case managers, yet staff nurses perform the admission assessment and find out more about the patients than anybody else. Include discharge planning tools in your care management workflows and involve case managers from the start. A discharge planning evaluation and assessment checklist guides discharge planners in identifying patients’ potential post-acute care needs. Despite its already low rate, increased regulatory focus on readmissions prompted Lorrie J. Reddish, RN, the hospital?s lead case manager, to reevaluate the case management department?s understanding of readmissions. DISCHARGE PLANNING . The Case Management Process: Planning ... care post hospital discharge such as home care services. Preventable readmissions can be controlled by comprehensive discharge planning. make it … Embed risk stratification tools in your EHR, notifying case managers early on where they are needed most, and remove barriers to discharge before they become an issue. Before implementing the Discharge Planning for Social Work Referral tool, Jennie Edmundson had a readmission rate of 8%. Hosp Case Manag. Case Management/Discharge Planning Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost effective outcomes. Post-acute care services that require pre- authorization: Acute Rehabilitative hospitalization Post-acute care services require Case Management enrollment and pre-authorization prior to the member transfer (Care at these levels may be covered as a benefit or as a benefit Discharge planning begins at admission. As consultants, Interim Leaders or as Mentors, we learn more about the culture of the staff, the physician and the patient at various hospitals and deal with exceptions. case management for over 20 years managing the most complex cases on the front lines and designing programs and processes for difficult patient populations as a special projects case manager. Tip: Create a discharge planning evaluation and assessment checklist Case Management Weekly, September 1, 2010. Case management insider. STEP 2: Reading The Discharge Planning Checklist Harvard Case Study: To have a complete understanding of the case, one should focus on case reading. Q. Medicare beneficiaries sometimes have information about discharge planning from CMS. When it comes to DC planning and patient satisfaction, most of the Case Management (CM) staff feels that they do not have much to do with delays in discharging […] When considering the discharge planning and communication for a specific patient, outpatient primary care practitioners reported higher scale values when they were involved in the discharge planning (median [25%, 75%] = 19 [19, 20.5]) than when they were not involved (17 [12.4, 19], P < 0.001). Discharge Planning: Diabetic Management Checklist Listing to ensure inclusion of essential information needed for disease management. 1 B-CARE Tool is a streamlined version of the CARE Tool specifically developed to be used by participants in the CMS Bundled Payment for Care As discharge planners, case management professionals are responsible for ensuring that the patient’s discharge is timely, safe, and appropriate. Medication Reconciliation Blank template Medication Administration Schedule Blank Template Discharge Summary Suggested Content General guideline for discharge documentation. Interview patients, assesses priorities, and develops appropriate discharge … Discharge planning is a universal priority for all acute care facilities that provide inpatient services. Included will be best-practice strategies for safely transitioning your patients across the continuum of care, as well as supportive case management roles for discharge planning outcomes. Federal Employee Program (FEP) Checklist for Discharge Planning . Involve Case Management Early On. This hospital discharge planning checklist may be used by health care workers to ensure that all of the appropriate steps have been taken in order to discharge a TB patient from the hospital. To provide approved mental health services with guidelines concerning practice in relation to case management and discharge planning in community settings. Tip: Use this checklist to prepare for discharge Case Management Weekly, August 24, 2011. Initially, fast reading without taking notes and underlines should be done. Case managers and clinical social workers work with patients and their families to coordinate: Discharge planning; Home care; Medical equipment ; Transportation; If you have any questions or need assistance, please contact the Case Management Department at 212.606.1271 between the hours of 9am and 5pm, Monday through Friday. These guidelines are intended to: Provide a framework for consideration of issues associated with discharge planning Both discharge planning and utilization review overlap with case management. 1. Discharge-related case management services billed on a member’s behalf who has entered a hospital inpatient unit, nursing facility, or intermediate care facility/mentally retarded (ICF/MR) (following an initial assessment or case plan) have … What questions might they ask as a result of having this information? Initiate Review morning rounds and afternoon rounds Address patient a. It is said that case should be read two times. A final rule revises and implements discharge planning requirements that hospitals, critical access hospitals (CAHs), and home health agencies (HHAs) must meet as a condition of participation (CoP) in the Medicare and Medicaid programs. • The Discharge Process and Documentation Checklist was developed using evidenced-based components from AHRQ’s RED Toolkit and included a team of the following: • Chief Nursing Officer • Directors • Managers • Case Management • Direct Patient Care RNs • … ... Develops appropriate and necessary case management strategies: 1 2 3: Discharge planning: 1 2 3: EVALUATION EXPERIENCE: Rank each of the following sections on a scale of 1 to 3: 1) Limited or no experience 2) Experienced, but may need review or supervision Include the following steps in your checklist: Identify patients’ potential for self-care AM education and – education needsAll patients discharge care. Hospitals need to ensure that discharge planning assessment is part of the job description for staff nurses,” Birmingham says. Discharge Planning Checklist for Case Managers Social Solutions Case Management Case managers and social workers are frequently asked to provide discharge planning for patients who have been receiving mental or physical health care at a hospital or other facility. 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