Legal Mandates/ Readmission Penalties
In 1975, this group defined dc planning as "that part of the continuity of care process which is designed to prepare the patient for the next phase of care, whether it be self care, care by family members or care by an organized healthcare provider."
What is the American Nurses Association
This model includes case finding and screening, patient assessment, resource assessment, problem identification, planning discharge, implementation, monitoring and documentation.
This is designed to intervene to arrest progression of or to palliate the disease, provide symptom relief, maintain, or stabilize the co morbid conditions, and transition the patient to the lowest necessary level of care.
What is the Medical Plan of Care?
This program may benefit a patient at WCH who is not homebound but needs nursing services that may help prevent readmissions.
What is Community Care Network?
This law sets mandates for discharge planning as a condition of participation for Medicare.
What is The Omnibus Reconciliation Act
This model aims to reduce preventable readmissions by engaging patients and families in discharge planning.
What is IDEAL discharge planning model?
This affects people of all ages, races, incomes and education levels. It is associated with worse health outcomes and higher costs.
What is limited or low Health Literacy?
This tool can be beneficial to identify patients with low health literacy and uses the question "How confident are you in filling out medical forms by yourself?"
What is the Single Item Literacy Screen (SILS)?
This regulation prohibits physicians from referring patients for a certain designated health service when the physician or immediate family member has a financial interest.
What is the Stark II Regulation
This model has 4 pillars including medication management, patient centered record, primary care physician/specialist follow up and knowledge of red flags.
What is Coleman's transition model?
This model is widely used to assist the care team in understanding the patient and/or family point of view in order to prepare a transition plan that is tailored to the uniqueness of the patient and/ or family. It is designed to elicit health beliefs.
What is The Kleinman Model?
What is culture?
In October 2012, CMS began to enforce a 30 day penalty for this.
What is Readmissions?
To move the patient to the least restrictive environment that can serve their needs is what?
What is the objective of transition management?
Understanding the patient's view of self, lifestyle, social supports, coping behaviors, mood and culture provides the healthcare team with a frame of reference. This model for identifying and gathering information is referred to as what?
What is the Self Pacing Model?
This person in the community may help "fill in the blanks" about the patient's outpatient care plan.
What is an ambulatory case manager?
The patient must be provided with choices of qualified providers, and the hospital may not limit or specify choices is an example of what?
What is a discharge planning standard?
The case manager performs this which serves as the primary vehicle to gather information about the patient's current psychosocial situation and resources and anticipate future transitional care needs.
What is a comprehensive assessment?
A patient's health insurance coverage or lack of, geography and compliance with treatment of medical diagnoses may be affected by this. Creative ways and constant communication with the supports may need to be used to meet the patient's needs.
What is access to care?
The estimated cost of limited health literacy to the nation's economy annually is this.