discharge planning checklist for case managers

” Only a doctor can authorize a patient ʼ s release from the hospital, but the actual process of discharge planning can be completed by a social worker, nurse, case manager, or other person. Case Management Team. 0000005473 00000 n development of, a discharge plan if the discharge planning evaluation indicates a need for a discharge plan. The surveyors will look for evidence of discharge planning activities and whether the staff are following the policies and procedures, Dill Calloway says. 0000520147 00000 n In such a case, the hospital must develop a 0000007104 00000 n The discharge planning worksheet that the Centers for Medicare & Medicaid Services developed for surveyors spells out what case managers should be doing to create an effective discharge plan. 1 B-CARE Tool is a streamlined version of the CARE Tool specifically developed to be used by participants in the CMS Bundled Payment for Care Clinical Skills and Knowledge. 0000516169 00000 n • Use the notes column to write down important information (like names and phone numbers). Case managers should have effective communication skills to accurately convey information to clients and build positive relationships. • Check the box next to each item when you and your caregiver complete it. The surveyors will check on compliance with requirements that hospitals track readmissions, assess patients who were readmitted, and change the discharge planning process to address the problems. Case managers can use the analytic capabilities of hospital CRM to find similar cases and base their identification of discharge timeline on previous experience. Case management nurses, as with discharge planners, work collaboratively with the healthcare team to meet the needs of the patient. The discharge planning worksheet offers hospitals a guide to complying with the revised discharge planning standards that went into effect July 19, 2013, Dill Calloway says. 0000076176 00000 n The Conditions of Participation require hospitals to have discharge planning policies and procedures and to follow them. Discharge Planning Checklist UC Irvine Healthcare case managers, clinical social workers and physician teams will: 1. 0000012413 00000 n Now, if hospitals don’t get it right, they could be cited for deficiencies,” says Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH. u�B]��PK�%[�̙f"��`&™f�9��xz�����Û�7o����zE��^Q��W�+�(�(�(�(�(�(�(�(g���2�"���_�̨Ȩ̨Ȩ̨Ȩ���i�h�h�l�l�l�l�l�l�l�l�l�l�l�l�l�l�i�B}�(�� �T�q�kO�[�iE浜w[���ks�at��� �H�b endstream endobj 228 0 obj <> endobj 229 0 obj <> endobj 230 0 obj <> endobj 231 0 obj <> endobj 232 0 obj <> endobj 233 0 obj [/ICCBased 269 0 R] endobj 234 0 obj <>stream 0000002250 00000 n %PDF-1.4 %���� Include the following steps in your checklist: Identify patients’ potential for self-care Determine post-acute case needs for treatment, monitoring, and education 0000010846 00000 n Case managers will need a more direct plan to include patients and their caregivers in the discharge planning process, in particular taking into account their individual “goals and preferences.” This discharge planning pro- cess will also need to start sooner—within 24 hours of admission. You must have JavaScript enabled to enjoy a limited number of articles over the next 360 days. • Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) about the items on this checklist. IU��W. 0000519974 00000 n 0000004904 00000 n 0000101575 00000 n AM education and – education needsAll patients b. write DC order PM – Anticipated discharges i for next AM if… 2. "Nine out of 10 hospitalists will tell you there's a wonderful advantage in working with a case manager on discharge planning," says Daniels. u�B]��PW�+�� 0000006773 00000 n Dill Calloway recommends that everyone in the hospital who discharges patients review the worksheets and incorporate all the elements of them into their policies and practices. Case Management & Discharge Planning. 0000002758 00000 n Surveyors will check to ensure that the discharge summary was sent to the patient’s primary care physician before the first follow-up visit or within seven days of discharge, Dill Calloway says. 0000009646 00000 n 0000010141 00000 n 0000006511 00000 n 0000126335 00000 n You and your family will work with our Case Management team, which includes your doctor, a social worker and/or a nurse case manager. 0000008340 00000 n Bridging the Discharge Gap: Complying with the CMS Discharge Planning Standards and Worksheet, Discharge Planning: CMS Worksheet & Standards. The worksheets are designed to help the surveyors and the hospital staff to identify when they are in compliance. Appendix B Mental Health: Discharge Plan Checklist ... programs may be made on a case-by-case basis. Planning must be indi vidualized, comprehensive and coordinated with community based services. If hospitals do not track their readmissions as part of discharge planning, they will be cited. • The Discharge Process and Documentation Checklist was developed using evidenced-based components from AHRQ’s RED Toolkit and included a team of the following: • Chief Nursing Officer • Directors • Managers • Case Management • Direct Patient Care RNs • … They will review five patient records to determine if discharge planners are assessing patients for their needs after discharge, giving patients a choice of post-acute providers, ensuring a timely discharge, and forwarding information on the hospital stay to providers at the next level of care. Rossi’s professional affiliations have included the American Association of Managed Care, the Speaking of the revenue cycle, timely discharge planning helps to avoid extended inpatient days and length of stay as well as payer denials. 0000047412 00000 n Early discharge planning. 0000012827 00000 n Objectives Explain the goals and process of discharge planning. • … Communication—both verbal and written—is key to a successful discharge. If your hospital doesn’t conduct a discharge planning evaluation for every patient, there must be a process to notify patients, family members, and attending physicians that they can request a discharge planning evaluation, even if the patient doesn’t meet high-risk criteria, she says. Describe considerations and needs for patients with pulmonary disease when transitioning out of the acute care setting. medical management, director of utilization review and case management, senior discharge planner, and marketing director in various provider and third-party payer settings. 0000017492 00000 n She suggests that hospitals use the worksheet as a self-assessment tool. • Discharges to supportive housing and/or halfway houses are beneficial. “It’s not just the hospital case managers and social workers who should be familiar with the worksheets and the discharge planning standards. The agency just announced that 2,610 hospitals forfeited $428 million in reimbursement because of excess readmissions. 0000016445 00000 n 0000003965 00000 n Findings and conclusions: Hospital-based case managers, responsible for discharge planning, have a unique opportunity to interact face-to-face with patients who are readmitted to determine factors that lead to the readmission. 0000011850 00000 n The Centers for Medicare & Medicaid Services (CMS) has issued the final worksheets for state and federal surveyors to use when they assess hospitals’ compliance with the Medicare Conditions of Participation for quality assessment and performance improvement, infection control, and discharge planning. Case managers should use the worksheet as a self-assessment tool to make sure they are complying with the CMS Conditions of Participation for discharge planning, according to an expert. DISCHARGE PLANNING . If your hospital stay is planned, discharge planning can begin even before your admission. “Hospitals have to comply with the Medicare Conditions of Participation or they could be fined or lose their ability to bill for Medicare and Medicaid,” Dill Calloway says. 0000007786 00000 n With penalties rising to 3% of reimbursement, hospitals should already be working on reducing readmissions,” she says. there are complex discharge needs, Hospital Case Management assistance must be requested. “CMS has been pilot-testing the worksheets since 2011. 0000003575 00000 n “These items are mandatory, not optional,” she says. Although the actual patient discharge appeared to reflect a smooth transition, the comments of the CRNs revealed a consistent lack of communication between disciplines and the patient. To understand the role of Case Management in the care of the dialysis patient 2. 0000005436 00000 n 1-800-370-9210 The discharge process is often met with mixed emotions from case managers. h�b```b``;������� ̀ �@16�#�Rd-a��,��%��Wl��,��U ��p�E�_8״�����f��1�S4 QpӘ��gZ_���u��Y64�vU�R�7�n���3m^W֚"/��K��L>�p�xg�*��E���J��@��H�Y�/����j5��{E4��,.ii���*�y�H������BJ� h ��o��1ۂE���f��a�P� ���������c�V_�5v� �8-��.0?c(e8�P�`������ a ��`����h���xY��&����:� B_��CD�k}`c�s�����A�hR{���c ���:X�0�c�P`x�+�Yo�1��#���~�)__��]�]�͝ ��N� �\�� endstream endobj 277 0 obj <>/Filter/FlateDecode/Index[40 184]/Length 29/Size 224/Type/XRef/W[1 1 1]>>stream “The worksheet is the gold standard of discharge planning. This checklist is designed to outline recommendations known to help in maintaining or establishing postpartum recovery. ReliasMedia_AR@reliasmedia.com, Do Not Sell My Personal Information  Privacy Policy  Terms of Use  Contact Us  Reprints  Group Sales, For DSR inquiries or complaints, please reach out to Wes Vaux, Data Privacy Officer, DPO@relias.com, Design, CMS, Hosting & Web Development :: ePublishing, Discharge Planning: CMS Worksheet and Standards, Creativity is the key to discharge planning for hard-to-place patients. To understand the overall assessment of the patient for needs determination 3. To assess the current processes and recommend improvements, the CRNs completed a short questionnaire after discharging a patient. Case Study on IDEAL Discharge Planning: Advocate Trinity Hospital ----- 22 References ----- 24. Discharge Planning Advisor: Is it redundant to have DPs in addition to CMs? Discharge planning through Valley's Care Coordination department and its team of case managers and social workers involves: Assessing your physiological, psychological, social and cultural needs 0000102454 00000 n Discharge planning is an Both discharge planning and utilization review overlap with case management. The worksheet calls for surveyors to interview patients or their representatives and attending physicians to find out if they are aware that they can request a discharge planning evaluation, she says. 0000126153 00000 n Case managers must possess knowledge of community health care options, vocational services and medical billing procedures. Case Management/Discharge Planning Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost effective outcomes. 0000016725 00000 n The Case Manager follows up with the patient and family on a routine basis to verify the discharge plan and on the day prior to discharge, sets up the simple discharge planning tasks to avoid potential delays and delivers the Medicare Important Message. Case Manager Skills Checklist. A discharge planning evaluation may be requested for any patient when there is an identified need. Before implementing the Discharge Planning for Social Work Referral tool, Jennie Edmundson had a readmission rate of 8%. These issues provided critical insight for understanding key drivers … 0000004377 00000 n They will look for evidence that the hospital is tracking readmissions, determining the reasons for readmissions, and making changes to address any problems. “CMS is putting a lot of emphasis on preventing readmissions. The surveyors will ask to see readmission data to confirm that hospitals are tracking readmissions as required by the standards, Dill Calloway says. Referral to these services and supports should be the standard of care. Communication. h�bbRf`b``Ń3� �a� R9� endstream endobj 225 0 obj <>/Metadata 38 0 R/Pages 37 0 R/StructTreeRoot 40 0 R/Type/Catalog/ViewerPreferences<>>> endobj 226 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 3/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 227 0 obj <>stream [ Microsoft Word version - 720.52 KB; PDF version - 188.59 KB] Be Prepared to Go Home Checklist … Comprehensive and coordinated with community based services to CMS level of care … case Manager in understanding barriers! To write down important information ( like names and phone numbers ) managers support... Halfway houses are beneficial checklist is designed to help the surveyors will ask to see readmission to! Part of discharge planning evaluation on every patient, Dill Calloway says extended inpatient days length... Social work referral tool, Jennie Edmundson had a readmission rate of 8 % to when! 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