Plan
Who is involved in discharge planning when it comes to the facility?
Physicians
Nurses
PT, OT, ST
Discharge Planner - may be a nurse or social worker
Third Party Payer Case Manager/Coordinator
To confirm information provided by the patient (Ex. Patient stated he will discharge home with significant other and he/she will be able to provide assistance on discharge)
When a patient is being discharged to another facility, what is the one MAIN requirement in order for patient to admit into the other facility?
DC orders
Patient is unable to ambulate and do things for him/herself. This patient can safely be discharged to Memphis Union Mission.
False
Patient is 300 lbs and traveling 8 hours away for IPR, and is MAX assist, what is the SAFEST way of transport for the patient?
Ambulance
who is involved in discharge planning when it comes to the patient?
Patient
Patient's family
Caregiver(s)
Legal guardian
What's more than likely the discharge plan for a patient that has walked 100ft with therapy?
What are the requirements for a patient to admit to IPR?
Need to be able to participate in at least 3 hrs of therapy (PT, OT, &/or ST) every day
Have support from family/friends upon discharge
Patient is 35 with medicaid but has a SCI, patient will be able to admit into an IPR.
False (case by case basis, can try to get acceptance for insurance but no guarentee)
Patient has walked 10 ft with therapy and family cannot afford transportation to Encompass Cane Creek, can this patient go by car?
Yes
Where are some places that discharge planning occurs?
1. Acute care hospital
2. Emergency Department
3. Inpatient rehab facility (IRF)
4. Skilled nursing facility (SNF): Subacute care and Long term care (LTC)
5. Long term care hospital (LTCH)
6. Patient's home: Assisted living facility (ALF), Group home, Retirement community, Family or friend's home
7. Outpatient clinic
Family unable to agree on discharge plan for elderly patient. One individual wants patient to discharge home while other wants SNF, patient does not have capacity to make her own decisions, who is the main person of contact in this situation?
POA
How many days does Medicare require for a patient to admit into another facility?
Medicare requires a 3 day qualified inpatient stay at a hospital
Social workers have up to 72 hours to complete an assessment on new patients on their floor.
False (48 hours)
Patient is medically ready, referrals have been sent to more than 3 facilities and all have denied the patient. Should you send out more referrals?
Escalate
Where do I get information to create a d/c plan?
1. patient
2. family members
3. Previous facility
4. Medical record
5. PT Examination
Patient is bed bound, how can we SAFELY discharge the patient home?
Family assistance, HH, and DME
ROHS are always running out of beds so it's best to have a ? _____
Plan B in place
Patient can discharge to Room In the Inn as long as they have 20 days worth of medication.
False (30 days)
John's familly have stated previously they will be able to take the patient home. Patient is medically ready now and patient's family state they are unable to take patient home, what should you IMMEDIATELY do next?
ESCALATE!!!
Why is discharge planning important?
1. Well-being of the patient
2. Smooth transition between facility to facility or facility to home
3. Reduce readmission rates
4. Continuity of care
5. Reduce overall cost
6. Meet regulatory compliance
7. Safety
Successful discharge planning involves ___ communication and _____ of care.
interdisciplinary, coordination
What is Wanda's infamous phrase on LOS call in the mornings?
"Escalate all barriers in real time"
Passion Place will accept any patient as long as they recieve a monthly income.
True
Amy is confused, unable to provide information for the discharge plan and no family contact information is on the chart. What are ways to locate patient's family?
Google search
901-545-COPS for wellness visit
Communicate with floor to get contact information for any visitors coming to see patient