Discharge Planning Basics
This is the first step in discharge planning and helps determine the patient’s post-hospital needs.
What is the initial assessment?
CMS requires hospitals to provide this written notice to Medicare patients before discharge, informing them of their rights to appeal.
What is the Important Message from Medicare (IMM)?
This week in October is celebrated nationally to recognize the work of case managers.
What is National Case Management Week?
This county-run service provides transportation for eligible residents to medical appointments, shopping, and other essential services.
What is Lake County Connection (paratransit service)?
This team member leads the patient’s medical care and makes the final decision on discharge readiness.
Who is the physician (or attending provider)?
Failure to arrange this Epic discharge milestone can contribute to readmissions and is often a CMS quality metric tracked after discharge.
What is the follow-up appointment?
This act, passed in 1986, requires hospitals to provide emergency medical screening and stabilizing treatment regardless of ability to pay.
What is EMTALA (Emergency Medical Treatment and Labor Act)?
This professional organization, founded in 1999, supports hospital and health system case managers through education, networking, and certification.
What is the American Case Management Association (ACMA)?
Located in Eustis, this clinic provides free and low-cost primary care services for uninsured Lake County residents.
What is Waterman Community Clinic?
This professional collaborates with care managers to ensure medication safety and provides patient education before discharge.
Who is the pharmacist?
Effective discharge planning requires engaging this group, who often provide transportation, medication support, and home safety oversight.
Who are the patient’s caregivers/family?
During discharge planning, CMS requires that patients and families be given this when selecting post-acute care providers.
What is patient choice of providers?
Hospital case management programs began gaining traction in the U.S. during this decade, partly to address rising healthcare costs and length of stay.
What are the 1980s?
This Lake County program connects uninsured adults with volunteer physicians for medical and dental care — and also provides durable medical equipment to those in need.
What is We Care of Lake County?
This discipline focuses on helping patients regain mobility and independence, often providing recommendations for safe discharge planning.
What is physical therapy?
This term describes when a patient’s discharge is delayed because community services, placement, or support are not yet available.
What is an avoidable day (or discharge delay)?
Hospitals must ensure that discharge planning includes an evaluation of the patient’s medical needs, functional status, and these social elements that impact safe discharge.
What are social determinants of health?
One of the primary goals of hospital case management is to reduce this costly occurrence, often measured within 30 days of discharge.
What is hospital readmission?
This Lake County nonprofit helps provide food assistance and other support for low-income families.
What is Lake Cares Food Pantry?
This role assists patients and families with psychosocial needs, community resources, and navigating post-discharge support systems.
Who is the social worker?
If a Medicare patient disagrees with their discharge, they have the right to request this process, which delays discharge until a review is completed.
What is a Medicare appeal (or Quality Improvement Organization appeal)?
Under CMS Conditions of Participation, hospitals must have this type of written plan that outlines how discharge planning will be conducted and monitored.
What is a hospital-wide discharge planning policy and procedure?
This credential, offered by ACMA, demonstrates specialized knowledge in hospital case management.
What is the ACM (Accredited Case Manager) certification?
This outreach ministry in Eustis provides meals, clothing, and referrals to homeless and low-income individuals.
What is Open Door Ministry?
This process brings together physicians, nurses, care managers, therapists, pharmacists, and others to align goals and create a safe discharge plan.
What is multidisciplinary rounds