What about those hospital discharges?
Who should be doing the discharge planning and who should be working with the patients and families to make sure the goals set for the patient are being achieved? Who is developing the discharge plan? These are all great and very important questions. Discharge planning should begin as soon as the patient sets a foot inside the hospital, whether that is just to the emergency room or is placed as an observation patient or inpatient.
This is another great reason for the admission case management model. The admission case manager begins the discharge assessment right at the time the patient is either placed in an observation or inpatient status. If the patient is discharged from the emergency room, our social worker works with the emergency room staff, patient, and/or families for appropriate discharge planning.
The seven day a week admission case management model at my hospital is guided by Imogene King’s Theory of Goal Attainment. This theory of goal attainment implies that nursing is to help people achieve, maintain or restore health through the mutual setting of goals (Hood & Leddy, 2006). The nurse and/or social worker and the patient come to agreement on a mutual goal to achieve; this brings the patient to the forefront and the most important being. There is interaction of the nurse/social worker and the patient in the appropriate environment that is most conducive of achieving the goal. Once the goal is agreed upon and set, the next step is defining what steps will be taken to reach the desired goal. Case management as it evolved became a process of assessment of patient needs (goal setting with the patient and or family), planning of care, arranging resources of services and ongoing coordination and evaluation of the care being provided.
Our model is successful because of teamwork. Our case managers and social workers work together with the patient and families as well as the other hospital disciplines, through interdisciplinary rounds to ensure that everyone is working toward the same goal for discharge.
Discharge is more than getting the patient out of the hospital door. It is making sure that the patient is going to a safe, agreed upon place with the appropriate resources available and in place. Successful discharges reduce those unwanted readmissions.
Reference:
Hood, L. J. & Leddy, S. K., (2006). Conceptual bases of professional nursing, (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
About the Author: Loretta Olsen, RN, has over twenty-eight years of experience in healthcare, from hospital staff positions to director level positions in various nursing practices, to experience the health insurance arena. She has worked as a product manager in group health insurance overseeing prescription drug plan designs, including implementing Medicare Part D. She also was the contract specialist in implementing disease management programs. She is currently the director of case management at Jennie Edmundson Hospital in Council Bluffs, Iowa. Olsen is pursuing her Masters of Science in Nursing.
Laura Ostrowsky | Jun 5, 2009 | Reply
I am the Director of Case Management at Memoria Sloan-Kettering Cancer Center. I agree that early discharge planning is essential. We currently have a case manager in outpatient who meets with elective patients prior to admission to begin the discharge planning process. Office practice nurses in ambulatory also alert inpatient case managers about patients with post discharge needs in advance of admission.
Discharge planning at Memorial is performed by nurse case managers. The inpatient case managers conduct an assessment of discharge planning needs at the time they perform their admission review and update the plan as needed throughout the patient stay.
Stefani | Jun 15, 2009 | Reply
Loretta – Our team has been relentlessly urging clients to focus on the access management component of the acute episode of care for exactly the reasons you cite. And with the RAC howling at the door, there is even more reason to begin the acute episode of care with a clear picture of the patients needs (inpatient vs obs), identification of any potential progression-of-care obstacles (throughput), and a tentative plan for probable post acute needs (transition). This is not rocket science, but with hospitals’ slavish focus on LOS, their commitment to access mgmt resources is not always where it should be.