Patient First
Why do we involve patients and families in discharge planning?
If involved, more likely to understand and follow through with their care. Engagement improves compliance, reduces anxiety, and empowers patients to take ownership of their recovery
Why is effective discharge planning critical to patient outcomes?
Effective discharge planning ensures patients leave the hospital with a clear, safe, and structured plan for their continued recovery. It reduces the risk of complications, prevents unnecessary readmissions, and ensures patients have access to the right level of care after leaving the facility.
Why do we have the provide the important message of medicare?
Finish this statement: "If you didn't document it___________
"It didn't happen"
Why is interdisciplinary collaboration essential?
When case managers, nurses, physicians, social workers, and other team members communicate effectively, they create a more comprehensive and realistic discharge plan. Each discipline brings a unique perspective that contributes to a safer and more successful transition of care.
Why is patient education everyone’s responsibility?
Every member of the care team matters
What happens when discharge planning is delayed or incomplete?
Lead to:
Extended hospital stays, increased health care, patient confusion for follow up, medication errors, higher rates of readmission.
Why do we have to complete the SBIRT (Screening brief intervention referral to treatment)?
What is the "Why" behind completing an initial assessmnet?
To appropriately assessment biopsychosocial needs of the patient to provide them supportive resources, making the transition from hospital admission to next level of care seamless.
What is the MAIN role difference between TCA and CMs
CM= creates a safe discharge plan
TCA: works to complete viable discharge plan made by the CM.
Why is discharge planning started on admission?
When does patient preference happen?
Preference starts during the initial assessment, when the RNCM/MSW explains the Discharge Process, Patient Preference and sets up expectations for future conversations.
Why do we utilize SDM/MPOA laws?
Failure to identify the correct SDM or MPOA can result in delayed DC, family conflicts, legal disputes that can significantly impact the patient's care and the facility's operations.
Why does real time documentation matter?
So others know the updates of where the plan is
Why is it important to check on peers if they are busy?
Because someday you might need the help. "Do one to others, you would want done to you."
Why do you have to document the patient's discharge barriers and delays in an ongoing note?
To relay to the clinical team the delays
Why do social determinants of health matter?
Factors such as housing instability, lack of transportation, limited social support, and food insecurity can significantly affect a patient's ability to recover safely at home. Addressing these factors during discharge planning helps prevent avoidable readmissions and ensures a truly safe discharge.
What does our readmission data tell us about the effectiveness of our current discharge planning process?
Our readmission data shows a patient who may have needed more support before, during, or after their discharge.
Why do we obtain patient signatures on DME delivery
Why is it important to communicate in person vs via teams
The message can be misunderstood through writing. Tone and body language cannot be seen via teams
Why is it important to start insurance authorization 3-5 days in advance and update the patient throughout the process?
To ensure the patient is familiar with the plan and there are no surprises when transport is arranged.
What is the true purpose of case management?
Improving patient outcomes through safe, coordinated, patient-centered care
Why is it important to spell out the stakeholders on the discharge note?
We no longer utilize abbreviations to ensure documentation is clear and concise for all clinical teams to avoid utilizing the wrong post acute provider
I.E: Haven Behavioral vs Haven of Hospice vs Haven Health Sky Harbor
Why is it important to document you have coordinated with the VA Case Manager?
To identify if the patient is service-connected vs Medicare recipient to work on the right DC plan.
Why is it important to notify the correct leader for escalations?
Each leader oversees a different area and may have additional insight on the case