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. 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. To assess the current processes and recommend improvements, the CRNs completed a short questionnaire after discharging a patient. 1. List the key standards for discharge planning as described by CMS. AM education and – education needsAll patients b. write DC order PM – Anticipated discharges i for next AM if… 2. 0000516239 00000 n However, the level of case management should be matched to clinical need and may range on a continuum from nominal case management to more active and assertive case management. 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. 0000008984 00000 n Clinical Skills and Knowledge. IU��W. 0000516323 00000 n Birmingham is the author of several books and journal articles about case management, discharge plan-ning, and transition management. Communication—both verbal and written—is key to a successful discharge. • Use the notes column to write down important information (like names and phone numbers). To understand the role of Case Management in the care of the dialysis patient 2. Surveyors will use the worksheet whenever a CMS survey is done. The surveyors will ask to see readmission data to confirm that hospitals are tracking readmissions as required by the standards, Dill Calloway says. Describe how social determinants of health can assist the Case Manager in understanding potential barriers 4. 0000016445 00000 n Initiate Review morning rounds and afternoon rounds Address patient a. Bridging the Discharge Gap: Complying with the CMS Discharge Planning Standards and Worksheet, Discharge Planning: CMS Worksheet & Standards. You and your family will work with our Case Management team, which includes your doctor, a social worker and/or a nurse case manager. 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. The Conditions of Participation require hospitals to have discharge planning policies and procedures and to follow them. Speaking of the revenue cycle, timely discharge planning helps to avoid extended inpatient days and length of stay as well as payer denials. 0000011850 00000 n 0000076176 00000 n Case managers can use the analytic capabilities of hospital CRM to find similar cases and base their identification of discharge timeline on previous experience. It’s a great tool that spells out what case managers should be assessing and what they should be doing to create an effective, comprehensive discharge plan, and ensure a smooth transition to the next level of care,” she says. Discharge planning should begin as soon as possible. 0000012827 00000 n Surveyors also are going to check for policies on requesting a discharge planning evaluation when there is a change in a patient’s status and evaluate whether the inpatient unit staff are aware of how, when, and whom to notify if there is a change, according to Dill Calloway. Discharge Planning Advisor: Is it redundant to have DPs in addition to CMs? • Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) about the items on this checklist. Discharge planning is yet another essential function of case managers, support coordinators and social workers. 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. Despite its already low rate, increased regulatory focus on readmissions prompted Lorrie J. Reddish, RN, the hospital?s lead case manager, to reevaluate the case management department?s understanding of readmissions. 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. You must have JavaScript enabled to enjoy a limited number of articles over the next 360 days. “The worksheet is the gold standard of discharge planning. If hospitals do not track their readmissions as part of discharge planning, they will be cited. Procedure/Checklist for Discharge Planning Tool for monitoring completion of new Mega-Rule requirements Discharge Planning Checklist List of actions to consider prior to and on the day of discharge 0000520147 00000 n 0000017453 00000 n "But to take full advantage of case managers' talents and expertise, hospitalists need to rely on [them] for so much more." 224 0 obj <> endobj xref 224 55 0000000016 00000 n 0000003575 00000 n Run checklist a. Discharge planning is an 0000102183 00000 n Planning must be indi vidualized, comprehensive and coordinated with community based services. 0000095850 00000 n Discharge Planning Checklist UC Irvine Healthcare case managers, clinical social workers and physician teams will: 1. 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. 0000519974 00000 n 0000007359 00000 n Nurses, social workers, case managers, and other appropriate hospital staff can use this to aid discharge planning. H�\��n�@E�|E/�Eī�*��%�N$/���`h;H1 ����ˍ2�X�}Tչ@���n�w�KNCs�;u};��p�������I^��k�ϣ巹�c�����:�˾? • Check the box next to each item when you and your caregiver complete it. “Case managers should document the appointment for the follow-up visit and make sure that the discharge summary gets into the hands of the primary care provider,” she says. 0000010846 00000 n 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. 0000010141 00000 n Case Managers Transitional Care Coordinators and Administrative Assistants. 0000047412 00000 n 0000006142 00000 n Objectives Explain the goals and process of discharge planning. 0000005473 00000 n Before implementing the Discharge Planning for Social Work Referral tool, Jennie Edmundson had a readmission rate of 8%. The agency just announced that 2,610 hospitals forfeited $428 million in reimbursement because of excess readmissions. [ Microsoft Word version - 720.52 KB; PDF version - 188.59 KB] Be Prepared to Go Home Checklist … The only difference before was that if you got something wrong, it couldn’t be held against you. %PDF-1.4 %���� This checklist is designed to outline recommendations known to help in maintaining or establishing postpartum recovery. 0000002250 00000 n 0000010704 00000 n Case managers must possess knowledge of community health care options, vocational services and medical billing procedures. 0000007786 00000 n The surveyors will look for evidence of discharge planning activities and whether the staff are following the policies and procedures, Dill Calloway says. 0000102454 00000 n Social Workers are available to provide Intervention to you and your family to help ease the Communication. Surveyors will review discharge planning policies and procedures and check to make sure the discharge planning staff are following them. 0000016725 00000 n 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 A frequent speaker, she has presented programs throughout the United States and in Great Britain and Spain. The best practice for hospitals is to conduct a discharge planning evaluation on every patient, Dill Calloway adds. Appendix B Mental Health: Discharge Plan Checklist ... programs may be made on a case-by-case basis. 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 Describe common barriers to discharge and ongoing Please click here to continue without javascript.. They’re Back! 0000001912 00000 n 0000520174 00000 n She suggests that hospitals use the worksheet as a self-assessment tool. Both discharge planning and utilization review overlap with case management. 0000012413 00000 n 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. 3. 0000003310 00000 n 1-800-370-9210 0000008340 00000 n "Nine out of 10 hospitalists will tell you there's a wonderful advantage in working with a case manager on discharge planning," says Daniels. • Discharges to supportive housing and/or halfway houses are beneficial. They will evaluate whether the five patients were given a choice of geographically convenient post-acute providers that could meet the patients’ needs, whether the patient’s caregiver was included in the discussions about post-acute care, and whether the discharge planning evaluation was completed early in the stay to avoid discharge delays, she says. 0000006511 00000 n 0000004377 00000 n List the outcome measures used to ensure the discharge planning process’success. • 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 • … 0000003965 00000 n With penalties rising to 3% of reimbursement, hospitals should already be working on reducing readmissions,” she says. 0000009646 00000 n Case managers and clinical social workers work with patients and their families to coordinate: Discharge planning; Home care; Medical equipment ; Transportation; If you have any questions or need assistance, please contact the Case Management Department at 212.606.1271 between the hours of 9am and 5pm, Monday through Friday. • (2) In the absence of a finding by the hospital that a patient needs a discharge plan, the patient's physician may request a discharge plan. 0000008957 00000 n Every nurse who discharges patients and the staff in the emergency department and outpatient clinics need to be informed as well,” she says. there are complex discharge needs, Hospital Case Management assistance must be requested. Case Manager Skills Checklist. 0000009120 00000 n development of, a discharge plan if the discharge planning evaluation indicates a need for a discharge plan. This request may be initiated by the patient and/or patient’s representative, family, hospital staff … Surveyors will review discharge planning policies and procedures and check to make sure the discharge planning staff are following them. 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. In such a case, the hospital must develop a Case management nurses, as with discharge planners, work collaboratively with the healthcare team to meet the needs of the patient. 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 0000126153 00000 n 0000101575 00000 n Ideally, and especially for the most complicated medical conditions, discharge planning is … If the patients were transferred to a post-acute setting, the surveyors will review the transfer form to ensure that it includes a brief reason for hospitalization, the course of treatment, the patient’s condition at discharge, a medication list, allergies, pending laboratory work, and a copy of the advance directives. “These items are mandatory, not optional,” she says. The team of Nurse Case Managers and Social Workers assist in assessing, planning and coordinating your care needs for a safe discharge. H�\��n�@���C� =ݱ�,9v"��?Z�> �����~��(+-�͇親Z��v������qhar��oc���w�ϖ�k�f�|���K=fyj>ܯS���ӐU�����)��æ��1��6Į?��?�ã��q���On��k׆S�зz�^_��綧}��w��)����}�+��%�4C�c݄X��U�t�]���u����^�v<5�u̪ŋE�%ޑw�W�+���>X��/Q_.�KpA.�%�Y����JV�� �L~��+���I,�� 0000126265 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. Case Study on IDEAL Discharge Planning: Advocate Trinity Hospital ----- 22 References ----- 24. Early discharge planning. Rossi’s professional affiliations have included the American Association of Managed Care, the 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. IDEAL Discharge Planning Overview, Process, and Checklist -- Handout that gives an overview of the IDEAL Discharge Planning process and includes a checklist that could be completed for each patient. “CMS has been pilot-testing the worksheets since 2011. They will look for evidence that the hospital is tracking readmissions, determining the reasons for readmissions, and making changes to address any problems. 0000002758 00000 n The worksheets will not be used by surveyors in critical access hospitals, but the staff in those hospitals should be familiar with them, Dill Calloway says. Find inspiration for your hospital to undertake discharge … 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. “Hospitals should be reviewing the charts of readmitted patients and analyzing why they were readmitted, then make changes to address any problems,” she adds. 0000004904 00000 n • … These issues provided critical insight for understanding key drivers … “CMS is putting a lot of emphasis on preventing readmissions. Private-Sector Hospital Discharge Tools. 0000006254 00000 n trailer <<18864DD477A947DFB9487BA19728C232>]/Prev 558662/XRefStm 1912>> startxref 0 %%EOF 278 0 obj <>stream Once Out of Favor, Clinical Pathways are Surging, Taking the lead in ensuring that pathways are followed, Worksheet is a guide to discharge planning CoPs, Hospital’s transition program coordinates care throughout the continuum, CMS sets the table for regulation requiring antibiotic stewardship programs. When it’s time to leave our hospital, we’re here to help you transition to the most appropriate place to continue your care. “It’s not just the hospital case managers and social workers who should be familiar with the worksheets and the discharge planning standards. New Requirements for Discharge Planning Includes information on the new Mega-Rule requirements for Discharge Planning that became effective 11/28/17. Policy 9.1.14 Patient Discharge Planning 11/01/92 -Originated 06/10/05 -Reviewed w/ changes 04/11/03 -Reviewed w/o changes Nursing Service -Author _____ Page 3 of 6 Roles in Discharge Planning, continued Care management: If the patient is unable, ensure the patient’s family/caregiver has been contacted as necessary to inform them of the 0000006028 00000 n 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. “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. 0000001396 00000 n DISCHARGE PLANNING . Case managers need to change their practice to include assessing patients on the basis of their prior level of care. Case Management & Discharge Planning. 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. 0000516169 00000 n Twenty-five questionnaires were completed within 2 weeks (86% of the total number of patients discharged). A discharge planning evaluation and assessment checklist guides discharge planners in identifying patients’ potential post-acute care needs. The discharge process is often met with mixed emotions from case managers. Describe considerations and needs for patients with pulmonary disease when transitioning out of the acute care setting. 0000519701 00000 n medical management, director of utilization review and case management, senior discharge planner, and marketing director in various provider and third-party payer settings. 0000017109 00000 n 0000007104 00000 n The worksheets are designed to help the surveyors and the hospital staff to identify when they are in compliance. 0000005436 00000 n 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. 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. Discharge Planning Checklist for Case Managers Social Solutions Case Management Case managers and social workers are frequently asked to provide discharge planning for patients who have been receiving mental or physical health care at a hospital or other facility. A discharge planning evaluation may be requested for any patient when there is an identified need. u�B]��PW�+�� 0000054529 00000 n Case managers should have effective communication skills to accurately convey information to clients and build positive relationships. Include the following steps in your checklist: Identify patients’ potential for self-care Determine post-acute case needs for treatment, monitoring, and education 0000126335 00000 n If your hospital stay is planned, discharge planning can begin even before your admission. 0000006773 00000 n The surveyors will review five patient records, a combination of patients admitted from home and from residential healthcare facilities, to determine if patients have a timely discharge planning evaluation, and if the discharge planning assessment takes into account the patient’s ability to perform activities of daily living and support in the community, she says. 0000017492 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. Referral to these services and supports should be the standard of care. The surveyors will examine discharge instructions and medication lists for the five patients and look for evidence that the patient and/or caregiver were educated on admission versus discharge medications, she says. 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 Discharge-related case management services billed on a member’s behalf who has entered a hospital inpatient unit, nursing facility, or intermediate care facility/mentally retarded (ICF/MR) (following an initial assessment or case plan) have … To understand the overall assessment of the patient for needs determination 3. A Sample of Private-Sector Hospital Discharge Tools Case studies of hospital discharge planning tools that strive to improve transitions to post-acute care and reduce readmissions. 0000002091 00000 n ” 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. 0000011292 00000 n 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 S representative, family, hospital staff … Early discharge planning Advisor: is it redundant to have in... Worksheet, discharge planning evaluation and assessment checklist guides discharge planners in identifying patients potential! Planning: Advocate Trinity hospital -- -- - 22 References -- -- - 24 and phone numbers ) their! 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Planners in identifying patients ’ potential post-acute care needs for a safe discharge, discharge planning CMS... Planning Advisor: is it redundant to have DPs in addition to CMS if! The healthcare team to meet the needs of the patient and/or patient ’ s representative family! Is yet another essential function of case management your caregiver complete it to help maintaining. Got something wrong, it couldn ’ t be held against you other appropriate staff! Next to each item when you and your caregiver complete it are following them speaker., as with discharge planners, work collaboratively with the healthcare team to meet the needs of the patient must. And in Great Britain and Spain management in the care of the revenue cycle, timely discharge planning and!