DISCHARGE PLANNING

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DISCHARGE PLANNING

• MUHA Division of Clinical Effectiveness/Case
  Management
• Jan 2009
• Time for completion 10 minutes

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Objectives

• After completing the lesson you will be able to
• 1.Describe the discharge planning process at MUSC
• 2. State your responsibility in reporting abuse
  and neglect at MUSC

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What is Discharge Planning?

• Includes all of the interventions that move a
  patient towards the best functional state,
  medical stability, and transfer to home or
  placement in a facility.
• Takes place throughout the continuum of care
• Proactive planning is the key to successful
  outcomes

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Who is Responsible for Discharge Planning?

• All team members, including nurse case managers,
  social workers, nursing, MDs, therapists, etc.
• The patient, family, or significant other
• All patient care staff are expected to be
  familiar with tools and team members essential to
  discharge planning

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Medical Social Worker

• Assists with patient transitions and discharge
  planning
• Performs psycho-social assessments
• Assists patients who
• -cannot afford their medications
• -have no health insurance
• -need transportation home
• -are homeless

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Medical Social Worker

• Oversees patient transition to nursing homes and
  residential care facilities
• Manages adoptions and child or adult custody
  cases
• Investigates assault and abuse cases for adults
  and children and reports them appropriately

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Nurse Case Manager

• Assesses patients disease process, history,
  treatment plan, and progress to determine needs
• Screens all patients for discharge planning
  needs, identifies complex/high risk patients
• Assists with clinically complex discharge needs
  and patients with insurance issues

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Nurse Case Manager

• Coordinates and facilitates implementation of
  discharge plans
• Shares resources and recommendations with MD team
• Helps keep MD team focused on optimal outcomes
  and appropriate utilization

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Availability

• Social Workers and Nurse Case Managers are
  available via pager 24 hours per day.
• Voice mail is available for communication of non
  emergent needs.

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Why is Discharge Planning Important?

• Improves patient flow by
• -providing seamless care
• -preventing readmissions
• -decreasing avoidable days
• Improves management of complex patients
• Increases patient, family, and staff satisfaction

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Discharge Planning

• Begins
• -Elective admissionsprior to admission if
  possible
• -Emergent or urgent admissionsat the time of
  admission
• Continues throughout hospital stay with
  evaluation and revision of plan if necessary

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How Can Staff Assist with Discharge Planning?

• Communicate with NCM/MSW as needed for high risk
  cases
• Participate in interdisciplinary rounds as
  dictated by each unit
• Complete documentation accurately (especially
  admission assessment and plan of care)

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How Can Staff Assist with Discharge Planning?

• Identify barriers to discharge, such as lack of
  funding or family support, or poor functional
  status
• Notify appropriate resources
• -Nurse Case Manager (NCM)
• -Medical Social Worker (MSW)
• -MD team

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How Can Staff Assist with Discharge Planning?

• DAY BEFORE DISCHARGE
• -Schedule labs, tests, or procedures early for
  day of discharge if possible
• -Make sure patient/family are aware of next
  day discharge and goal of 1100 am discharge time
• -Make sure patient confirms ride home (if no
  ride, call MSW)

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How Can Staff Assist with Discharge Planning?

• DAY BEFORE DISHARGE
• -Complete specialized patient education
• -Develop plan for obtaining medicationscall
  MSW if no plan

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How Can Staff Assist with Discharge Planning?

• DAY OF DISCHARGE
• -Ensure discharge orders are signed, reviewed,
  and transcribed
• -Ensure that home health referrals are
  completed and DME is delivered (call NCM if you
  need help)
• -Ensure transfer packets are completed if
  patient is going to a facility
• -Ensure discharge instructions are completed

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Discharge Dispositions

• Discharge disposition refers to where a patient
  is discharged (i.e., home, home with home health,
  nursing home, etc)
• Ensure that the correct discharge disposition is
  assigned on discharge orders and OACIS upon
  patient discharge
• This is a compliance issue

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Always remember.

• Discharge planning is an important aspect of
  patient care at MUSC
• Be proactive
• Utilize resources (including your NCM and MSW!)

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Identifying and Reporting Abuse and Neglect

• MUHA Division of Clinical Effectiveness/Case
  Management

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Reporting Abuse and Neglect

• Categories
• Vulnerable Adult
• Child
• MUHA policy C-7 on the Intranet
• Criteria and guidelines for healthcare personnel
  to identify and assess
• Notification of the Social Worker for further
  assessment and reporting to appropriate
  authorities
• Also covers Physical Assault, Sexual Assault/Rape
  and Domestic violence/Abuse for patients that do
  not fall under the definitions of vulnerable
  adults or children

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Reporting Abuse and Neglect

• Suspected physical or psychological abuse,
  neglect, or exploitation of a vulnerable adult or
  child must be reported under the laws of the
  State of SC.
• Suspected cases are to be reported to a social
  worker 24 hours a day, 7 days a week

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Reporting Abuse and Neglect

• Failure to report can lead to civil and criminal
  penalties
• All healthcare providers are mandated reporters
• SCAN-Suspected Child Abuse Neglect
• -Social worker completes forms if suspected
  victim is a child

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Congratulations!

• You have completed this lesson. Please complete
  test now.