discharge planning checklist for case managers

This request may be initiated by the patient and/or patient’s representative, family, hospital staff … Both discharge planning and utilization review overlap with case management. Discharge planning is an 0000519701 00000 n 0000006511 00000 n Please click here to continue without javascript.. They’re Back! If the patients were transferred to a post-acute setting, the surveyors will review the transfer form to ensure that it includes a brief reason for hospitalization, the course of treatment, the patient’s condition at discharge, a medication list, allergies, pending laboratory work, and a copy of the advance directives. 0000007104 00000 n “Hospitals should be reviewing the charts of readmitted patients and analyzing why they were readmitted, then make changes to address any problems,” she adds. 0000011850 00000 n Case managers must possess knowledge of community health care options, vocational services and medical billing procedures. “Case managers should document the appointment for the follow-up visit and make sure that the discharge summary gets into the hands of the primary care provider,” she says. She suggests that hospitals use the worksheet as a self-assessment tool. “These items are mandatory, not optional,” she says. The best practice for hospitals is to conduct a discharge planning evaluation on every patient, Dill Calloway adds. 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. IU��W. Case Study on IDEAL Discharge Planning: Advocate Trinity Hospital ----- 22 References ----- 24. The only difference before was that if you got something wrong, it couldn’t be held against you. u�B]��PK�%[�̙f"��`&™f�9��xz�����Û�7o����zE��^Q��W�+�(�(�(�(�(�(�(�(g���2�"���_�̨Ȩ̨Ȩ̨Ȩ���i�h�h�l�l�l�l�l�l�l�l�l�l�l�l�l�l�i�B}�(�� �T�q�kO�[�iE浜w[���ks�at��� �H�b endstream endobj 228 0 obj <> endobj 229 0 obj <> endobj 230 0 obj <> endobj 231 0 obj <> endobj 232 0 obj <> endobj 233 0 obj [/ICCBased 269 0 R] endobj 234 0 obj <>stream The worksheet calls for surveyors to interview patients or their representatives and attending physicians to find out if they are aware that they can request a discharge planning evaluation, she says. 0000519974 00000 n 0000095850 00000 n Before implementing the Discharge Planning for Social Work Referral tool, Jennie Edmundson had a readmission rate of 8%. You and your family will work with our Case Management team, which includes your doctor, a social worker and/or a nurse case manager. • Check the box next to each item when you and your caregiver complete it. A frequent speaker, she has presented programs throughout the United States and in Great Britain and Spain. Objectives Explain the goals and process of discharge planning. h�b```b``;������� ̀ �@16�#�Rd-a��,��%��Wl��,��U ��p�E�_8״�����f��1�S4 QpӘ��gZ_���u��Y64�vU�R�7�n���3m^W֚"/��K��L>�p�xg�*��E���J��@��H�Y�/����j5��{E4��,.ii���*�y�H������BJ� h ��o��1ۂE���f��a�P� ���������c�V_�5v� �8-��.0?c(e8�P�`������ a ��`����h���xY��&����:� B_��CD�k}`c�s�����A�hR{���c ���:X�0�c�P`x�+�Yo�1��#���~�)__��]�]�͝ ��N� �\�� endstream endobj 277 0 obj <>/Filter/FlateDecode/Index[40 184]/Length 29/Size 224/Type/XRef/W[1 1 1]>>stream • (2) In the absence of a finding by the hospital that a patient needs a discharge plan, the patient's physician may request a discharge plan. Clinical Skills and Knowledge. Case managers should use the worksheet as a self-assessment tool to make sure they are complying with the CMS Conditions of Participation for discharge planning, according to an expert. Initiate Review morning rounds and afternoon rounds Address patient a. 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. 0000012413 00000 n DISCHARGE PLANNING . trailer <<18864DD477A947DFB9487BA19728C232>]/Prev 558662/XRefStm 1912>> startxref 0 %%EOF 278 0 obj <>stream 0000017109 00000 n Every nurse who discharges patients and the staff in the emergency department and outpatient clinics need to be informed as well,” she says. 0000054529 00000 n They will review five patient records to determine if discharge planners are assessing patients for their needs after discharge, giving patients a choice of post-acute providers, ensuring a timely discharge, and forwarding information on the hospital stay to providers at the next level of care. Bridging the Discharge Gap: Complying with the CMS Discharge Planning Standards and Worksheet, Discharge Planning: CMS Worksheet & Standards. The surveyors will ask to see readmission data to confirm that hospitals are tracking readmissions as required by the standards, Dill Calloway says. 0000017492 00000 n Speaking of the revenue cycle, timely discharge planning helps to avoid extended inpatient days and length of stay as well as payer denials. Now, if hospitals don’t get it right, they could be cited for deficiencies,” says Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH. The surveyors will check on compliance with requirements that hospitals track readmissions, assess patients who were readmitted, and change the discharge planning process to address the problems. 0000003965 00000 n 0000101575 00000 n The worksheets are designed to help the surveyors and the hospital staff to identify when they are in compliance. Discharge Planning Advisor: Is it redundant to have DPs in addition to CMs? 0000516169 00000 n 224 0 obj <> endobj xref 224 55 0000000016 00000 n The discharge planning worksheet that the Centers for Medicare & Medicaid Services developed for surveyors spells out what case managers should be doing to create an effective discharge plan. The Centers for Medicare & Medicaid Services (CMS) has issued the final worksheets for state and federal surveyors to use when they assess hospitals’ compliance with the Medicare Conditions of Participation for quality assessment and performance improvement, infection control, and discharge planning. Case management nurses, as with discharge planners, work collaboratively with the healthcare team to meet the needs of the patient. medical management, director of utilization review and case management, senior discharge planner, and marketing director in various provider and third-party payer settings. • … The surveyors will look for evidence of discharge planning activities and whether the staff are following the policies and procedures, Dill Calloway says. Discharge planning should begin as soon as possible. 0000017453 00000 n They will look for evidence that the hospital is tracking readmissions, determining the reasons for readmissions, and making changes to address any problems. They will evaluate whether the five patients were given a choice of geographically convenient post-acute providers that could meet the patients’ needs, whether the patient’s caregiver was included in the discussions about post-acute care, and whether the discharge planning evaluation was completed early in the stay to avoid discharge delays, she says. development of, a discharge plan if the discharge planning evaluation indicates a need for a discharge plan. 0000001396 00000 n If your hospital doesn’t conduct a discharge planning evaluation for every patient, there must be a process to notify patients, family members, and attending physicians that they can request a discharge planning evaluation, even if the patient doesn’t meet high-risk criteria, she says. H�\��n�@E�|E/�Eī�*��%�N$/���`h;H1 ����ˍ2�X�}Tչ@���n�w�KNCs�;u};��p�������I^��k�ϣ巹�c�����:�˾? Dill Calloway recommends that everyone in the hospital who discharges patients review the worksheets and incorporate all the elements of them into their policies and practices. 0000126153 00000 n To understand the role of Case Management in the care of the dialysis patient 2. ReliasMedia_AR@reliasmedia.com, Do Not Sell My Personal Information  Privacy Policy  Terms of Use  Contact Us  Reprints  Group Sales, For DSR inquiries or complaints, please reach out to Wes Vaux, Data Privacy Officer, DPO@relias.com, Design, CMS, Hosting & Web Development :: ePublishing, Discharge Planning: CMS Worksheet and Standards, Creativity is the key to discharge planning for hard-to-place patients. Case Managers Transitional Care Coordinators and Administrative Assistants. Appendix B Mental Health: Discharge Plan Checklist ... programs may be made on a case-by-case basis. “It’s not just the hospital case managers and social workers who should be familiar with the worksheets and the discharge planning standards. However, the level of case management should be matched to clinical need and may range on a continuum from nominal case management to more active and assertive case management. 0000126265 00000 n Discharge Planning Checklist UC Irvine Healthcare case managers, clinical social workers and physician teams will: 1. 0000102183 00000 n 0000002758 00000 n 0000006142 00000 n Procedure/Checklist for Discharge Planning Tool for monitoring completion of new Mega-Rule requirements Discharge Planning Checklist List of actions to consider prior to and on the day of discharge List the key standards for discharge planning as described by CMS. Case managers will need a more direct plan to include patients and their caregivers in the discharge planning process, in particular taking into account their individual “goals and preferences.” This discharge planning pro- cess will also need to start sooner—within 24 hours of admission. 0000009120 00000 n “CMS is putting a lot of emphasis on preventing readmissions. 0000007359 00000 n Describe considerations and needs for patients with pulmonary disease when transitioning out of the acute care setting. 0000516323 00000 n 0000009646 00000 n In such a case, the hospital must develop a 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. Discharge planning is yet another essential function of case managers, support coordinators and social workers. 0000008984 00000 n 0000003310 00000 n 0000010846 00000 n 0000006028 00000 n 1-800-370-9210 Find inspiration for your hospital to undertake discharge … Referral to these services and supports should be the standard of care. %PDF-1.4 %���� “The worksheet is the gold standard of discharge planning. 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. 0000010141 00000 n The surveyors will examine discharge instructions and medication lists for the five patients and look for evidence that the patient and/or caregiver were educated on admission versus discharge medications, she says. 0000008340 00000 n New Requirements for Discharge Planning Includes information on the new Mega-Rule requirements for Discharge Planning that became effective 11/28/17. 0000011292 00000 n 0000010704 00000 n 0000047412 00000 n Communication. 0000076176 00000 n To understand the overall assessment of the patient for needs determination 3. Case Management & Discharge Planning. • 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 • … 1. 0000016725 00000 n 0000002250 00000 n To assess the current processes and recommend improvements, the CRNs completed a short questionnaire after discharging a patient. The Conditions of Participation require hospitals to have discharge planning policies and procedures and to follow them. 0000016445 00000 n Early discharge planning. Ideally, and especially for the most complicated medical conditions, discharge planning is … 0000006254 00000 n “CMS has been pilot-testing the worksheets since 2011. • Discharges to supportive housing and/or halfway houses are beneficial. List the outcome measures used to ensure the discharge planning process’success. there are complex discharge needs, Hospital Case Management assistance must be requested. It’s a great tool that spells out what case managers should be assessing and what they should be doing to create an effective, comprehensive discharge plan, and ensure a smooth transition to the next level of care,” she says. These issues provided critical insight for understanding key drivers … 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. 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. With penalties rising to 3% of reimbursement, hospitals should already be working on reducing readmissions,” she says. Case managers should have effective communication skills to accurately convey information to clients and build positive relationships. “Hospitals have to comply with the Medicare Conditions of Participation or they could be fined or lose their ability to bill for Medicare and Medicaid,” Dill Calloway says. Once Out of Favor, Clinical Pathways are Surging, Taking the lead in ensuring that pathways are followed, Worksheet is a guide to discharge planning CoPs, Hospital’s transition program coordinates care throughout the continuum, CMS sets the table for regulation requiring antibiotic stewardship programs. 0000516239 00000 n "But to take full advantage of case managers' talents and expertise, hospitalists need to rely on [them] for so much more." Twenty-five questionnaires were completed within 2 weeks (86% of the total number of patients discharged). Findings and conclusions: Hospital-based case managers, responsible for discharge planning, have a unique opportunity to interact face-to-face with patients who are readmitted to determine factors that lead to the readmission. Birmingham is the author of several books and journal articles about case management, discharge plan-ning, and transition management. Describe common barriers to discharge and ongoing u�B]��PW�+�� If hospitals do not track their readmissions as part of discharge planning, they will be cited. 0000006773 00000 n 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 Communication—both verbal and written—is key to a successful discharge. When it’s time to leave our hospital, we’re here to help you transition to the most appropriate place to continue your care. A discharge planning evaluation may be requested for any patient when there is an identified need. The surveyors will review five patient records, a combination of patients admitted from home and from residential healthcare facilities, to determine if patients have a timely discharge planning evaluation, and if the discharge planning assessment takes into account the patient’s ability to perform activities of daily living and support in the community, she says. • Use the notes column to write down important information (like names and phone numbers). Although the actual patient discharge appeared to reflect a smooth transition, the comments of the CRNs revealed a consistent lack of communication between disciplines and the patient. Surveyors also are going to check for policies on requesting a discharge planning evaluation when there is a change in a patient’s status and evaluate whether the inpatient unit staff are aware of how, when, and whom to notify if there is a change, according to Dill Calloway. "Nine out of 10 hospitalists will tell you there's a wonderful advantage in working with a case manager on discharge planning," says Daniels. Surveyors will review discharge planning policies and procedures and check to make sure the discharge planning staff are following them. Private-Sector Hospital Discharge Tools. 0000003575 00000 n 0000007786 00000 n 0000004904 00000 n If your hospital stay is planned, discharge planning can begin even before your admission. The Case Manager follows up with the patient and family on a routine basis to verify the discharge plan and on the day prior to discharge, sets up the simple discharge planning tasks to avoid potential delays and delivers the Medicare Important Message. • Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) about the items on this checklist. Case managers can use the analytic capabilities of hospital CRM to find similar cases and base their identification of discharge timeline on previous experience. Surveyors will check to ensure that the discharge summary was sent to the patient’s primary care physician before the first follow-up visit or within seven days of discharge, Dill Calloway says. Before implementing the discharge planning for social work referral tool, Jennie Edmundson had a readmission rate 8. Safe discharge potential barriers 4 held against you, and other appropriate hospital staff … Early discharge.. 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