Challenges for case managers in discharge planning
Discharge planning is a constant state of mind for our case management team. We continually strive to create a plan that is safe and comprehensive.
Discharge planning is also a major focus of accrediting agencies including both The Joint Commission (formerly JCAHO) and the Centers for Medicare & Medicaid Services (CMS). Our case management team has found that creating a safe discharge plan and initiating a thorough multidisciplinary assessment (including functional, psychological, and cognitive) within the first twenty-four hours has been a challenge. The challenge in safe discharge planning is usually the coordination of critical communication of all team members.
According to CMS interpretive guidelines, staff performing discharge planning will be interdisciplinary in nature.
CMS Interpretive Guidelines ยง482.43(b)(2)
The responsibility for discharge planning is often multidisciplinary. It is not restricted to a particular discipline. The hospital has flexibility in designating the responsibilities of the registered nurse, social worker, or other appropriate qualified personnel for discharge planning. The responsible personnel should have experience in discharge planning, knowledge of social and physical factors that affect functional status at discharge, and knowledge of community resources to meet post-discharge clinical and social needs.
-Ideally, discharge planning will be an interdisciplinary process, involving disciplines with specific expertise, as dictated by the needs of the patient. (CMS interpretive guideline, 2009)
Our team is working on the following to improve discharge planning communication of care:
1. Purchase of an electronic discharge planning software to coordinate critical communication in transition of care to outside facilities.
2. Communication tools for hand-off of care.
a. Hand-off of care communication tool is used from unit to unit in hospital so that communication of all components of the initial discharge plan are not lost
b. Communication tool to be used during finalization of a safe discharge plan and ensuring communication is complete to all members of the team.
3. Improved lists of community support (skilled facilities, hospice agencies, home health, etc. ) for patients /families to use to ensure they are provided choices ( We also have available online virtual screens where they can see community resources and photos of services provided)
4. Interdisciplinary team rounds.
At Scottsdale Healthcare, we try to analyze gaps and communication and feel communication and documentation are major components of successful discharge planning.
What do you feel are the most important components of discharge planning. What discharge planning tools have you found to be successful?
About the Author: Karen R Ford MSN, RN is the director of case management at Scottsdale Healthcare System in Scottsdale, AZ.
Jackie Birmingham | Mar 5, 2009 | Reply
The comments by Karen Ford were very comprehensive and it contains a wealth of information.
The one area I noted that might give more insight is the one about requiring an assessment “within the first twenty-four hours” The CMS rule states that the ‘assessment’ must be done on a ‘timely’ basis and does not specifically state 24 hours.
What I have found to be a great discharge planning tool is the development of a ‘high-risk screening tool’ aka ‘case finding’ tool. This tool can be service specific (ortho or cardiac for example) and can be a way to identify, within 24 hours, a patient at risk for an ‘adverse health outcome’, or a potential avoidable delay in discharge.
The ‘assessment’ for potential post-acute needs is then done when the patient is stable and the needs are better known. Discharge planning starts on admission with the ‘screening’ and progresses with assessment, re-assessment, planning and implementation.
The screening process is also multidisciplinary and requires all who work with the patient close to admission, and after, to be on alert for clues of potential post acute needs.
Please let me know if this makes sense.
Regards,
Jackie Birmingham, RN, MS
Robert Hodges | Mar 10, 2009 | Reply
At the last location I worked, our policy was that discharge planning had to be initiated within 48 hours of admission or on the next business day since case management was not on the units 7 days a week. Initially all discharge planning notes were printed(case management had it’s own software package for UR and discharge planning which all case management staff used and read)and placed in the paper record under their own tab which no one looked at and which often ended up being large stacks of paper because everyone would add the new, but no one would remove the old.
Once we transitioned to an electronic medical record, the discharge planning notes also transitioned and suddenly everyone was reading them. You could also tell very quickly who had not had discharge planning initiated and what everyone was doing since all the discharge planning notes were in the same place and identified by the “author type” of “Case Manager” or “Social Worker”.
Communication is the key to success in every endevour. The challenge is sometimes teaching the physician, nurse, therapist, etc which tab to flip to in the chart and then getting them to read it and to provide input.
Interdisciplinary rounds are helpful if you can make them happen. What worked for us was a quick down and dirty with the unit charge nurses, case manager and social worker. That way everyone got a quick update and knew the plan of the day.
Finally, we had a folder on the shared computer network that contained a huge amount of discharge planning resources. These were put together by social work and case management, and everyone in the hospital had access. It included everything from a list of ventilator facilities, phone numbers for community support resources, to the prior auth forms for prescriptions from different payers. It was a huge and greatly valued resource. We were working on organizing this and putting the list on the hospital intranet for staff availablity at my departure.
You do everything you can with the tools at your disposal.
Jackie Birmingham | Mar 11, 2009 | Reply
Last October (10/17/2008) CMS published a revision to the Interpretive Guidelines (IG) that is used by surveyors (Joint Commission as an example) to review processes in hospitals to assure that the hospital is following the Conditions of Participation (COP). I received a few emails asking if there was a new ‘COP’. There is not a new COP – at least since October of 2004, but there are new guidelines. This IG can be found at this website (think it only opens in Firefox – not IE browser)
http://www.cms.hhs.gov/manuals/Downloads/som107ap_a_hospitals.pdf
Section 482.43 relates to Discharge Planning. Very good resource on what surveyors look for, where the look (chart, interview staff, interview patients.
You may also want to do a word search for ‘Important Message’ – tells you exactly what is expected – follow-up copy, etc. It’s in the section on ‘patient’s rights’.
Loretta Olsen | Mar 25, 2009 | Reply
Karen, we have just completed implementation of a 7 day a week case management design, with the inclusion of admission case managers. We cover the hosptial from 7AM-7PM seven days a week. The admission case managers do the patient’s admission history, their medication reconciliation, assess the patient for any Present on Admission conditions and do the initial case management discharge assessment. This way we can begin discharge planning at the time of admission. We also do interdisciplinary rounds and discuss the discharge planning and any barriers to discharge planning.
Loretta
Stefani | Mar 25, 2009 | Reply
I take a slightly different position than my esteemed colleagues. Disharge planning should not be “a constant state of mind” for the case manager. I suggest that progression-of-care is a more practical reference model for the practice of hospital case mgmt. If the CM is seen as the navigator for progression-of-care from the time of admission, planning for transition becomes a natural part of the process.
And as far as ‘screening’ patients – I’ve been rigid about my position for over 20 years!! Screening is most appropriately done at the time of the patient’s initial admission assessment completed by nursing within 24 hrs of admission. Screening criteria is/can be built into that tool. If indicators, either singly or in combination, are triggered, they result in a case mgt referral for an assessment. Nursing handles routine progression-of-care and transition for all other patients.
There, I said it!
Jackie Birmingham, RN, MS | Mar 27, 2009 | Reply
From what I read of the note, Stefani’s position is right on target regarding the ‘screening’ at initial assessment by nursing at admission. It is an essential part of the nursing process…identify needs – including those needs of the patient for safe transition. However, discharge planning should be a constant state of mind for the case manager, because it is a fundamental, patient centric process in the progression of the PATIENT to the most appropriate next level of care, be it to a higher or lesser level. If the idea that the patient is not in one place for care for very long, the navigation for the progression of care is essentially what discharge planning is. If done by focusing on the patient(rather than the LOS) in the process there is merit to staying focused. The wide spread concept of not addressing ‘discharge planning’, but rather progression or transition is one that implies the notion that case management process extends beyond the walls of any care setting. This is good. But, the fact that the process of ‘discharge planning’ is the term used in Federal Regulations, it is essential that the case manager have the process in a constant state of mind. And finally, I believe that what case management is today is founded on the discharge planning process developed and written into law more than 20 years ago.
Thanks for listening (reading)
Jackie
Gwyn Grant | Jun 4, 2009 | Reply
Hi,
I was wondering if anyone would be willing to share a sample of their “high risk screening tool”
Thanks
Gwyn
DeAnne Hunt | Oct 6, 2009 | Reply
Do you have a screening or case finding tool wondering if you would be willing to share it with me.
Thanks.
judy | Oct 23, 2009 | Reply
Very intereseted in your model . What is the your nurse pt ratio? How many beds is your facility? Are you staff assigend to floors or geographical locations? Are they responsible for insurance reviews.Sorry just so interested.
Looking to do a redesign of our department. Trying to make d/c planning nurse centered, and the social worker to do true social work. Use case manager associates to do anything clerical for the discharge.
DIANE BELLAFRONTO | Dec 15, 2009 | Reply
Would anyone be willing to share with me:
a) a high risk screening tool and
b) a discharge planning policy?
Many thanks and Happy Holidays.
Diane Bellafronto
Director Care Management
Norton Healthcare
Louisville, KY 40202
April Brown | Mar 2, 2010 | Reply
I was wondering if you could share your high risk assessment screening tool.
Thanks in advance,
April Brown
Adventist Health System
Project Manager Case Management
Orlando, Florida
phyllis caputo | Sep 6, 2010 | Reply
Do you believe it is beneficial for a Case Manager to document her utilization review notes (clincial updates) in the discharge planning note on an ongoing basis? Does this help with reimbursement or in some other way?
Hand-Off Communication | Mar 17, 2011 | Reply
Live communication between the whole health care team is critical in reducing errors – but having it work consistently takes a process. Vocera Communications – the wireless communications group has built a great hand-off product that works and is exclusively endorsed by the AHAA.
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