As a Case Manager working in a hospital environment, getting patients moved through the continuum of care is high on the list. Discharge planning (DP) is crucial for a smooth transition. It starts on the day of admission when the Case Manager sees the patient/family for the first time to do an admission assessment. Discharge planning continues throughout the patient stay. The Case Manager attends round with the Doctor, Nurse Practitioner, and Pharmacist to discuss the plan of care for the patient with an anticipated discharge date. The Case Manager collaborates with the team to anticipate the needs of the patient and set the DP in motion.
In 2004, the JACHO addressed a guideline that looked at issues of clients moving through the hospital,
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The night Nurse would look into making sure that transport is available, collecting patient belongings, finding the location of the pharmacy. D/C instructions can also begin during the evening shift. Any PT/OT, Case Management or Social Work need, consultation or treatments are addressed early in the day shift to achieve the 11:00am discharge goal. Clinical Nurse Leader were also involved by assisting the staff nurses with D/C needs. Ultimately, the discharge by 11:00am program initiation became the standard in DP and was …show more content…
References
Gray, E.A., Santiago, L. Dimalanta, M. I., Maxton, J., Aronow, H. U. (November-December 2016).
Discharge by 11:00 a.m.: The Significance of Discharge Planning. Medsurg Nursing, 25(6), 381-384.
Wrobleski, D. M., Joswiak, M. E., Dunn, D. F., Maxson, P.M., & Holland, D. E. (March-April 2014).
Discharge Planning Rounds to the Bedside: A Patient and Family Centered Approach. Medsurg
Nursing, 23(2),
Discharge planning is used to create a plan of care for a patient who is leaving a care setting. An evaluation is done to determine the patient’s continuing care needs once they have left the care facility. When patients are send back home or to a facility that does not require full time nursing care assistance, programs need to be put into place to ensure that the patient is receiving the proper continuation of care post discharge. Proper discharge planning can decrease the chances of a hospital readmit, help in recovery, ensure medications are prescribed and given correctly, and adequately prepare family or caregivers to assume proper post discharge care. According to the Family Caregiver Alliance, “It is important, not only for patients, but family
This week’s reflection paper focuses practice-based evidence and the operation of the theoretical framework of person-in-environment as each relates to discharge planning at UMPC Mercy Detoxification Unit (UPMC-MDU).
In 1974, the federal government adopted the Uniform Hospital Discharge Data Set (UHDDS) as the standard to help improve the uniformity and comparability of hospital discharge data, the principal diagnosis, and other diagnoses for hospital procedures; including comparable data that could help to determine which hospitals were best at treating patients and for reporting inpatient data in acute care, short-term care, and long-term care hospitals. This dataset works towards a standardized system of reimbursement for the federal government nationwide which in turn could lower costs, UHDDS helps in collecting general information pertaining the patient and the specific care including the age, sex, and race of the patient. The data elements are collected
The hospital that I worked for while working as a case manager was not in network with Kaiser Permanente. It was also the time when the hospital started to hire hospitalists to manage patient care while they are a patient in the hospital. It actually worked out because it filled in the gap in patient care. The hospitalists were acting as the patient's primary care provider. Kaiser as with many other insurance have a case manager designated to ensure that the patient is meeting criteria not only for an inpatient hospital stay but for the level of care they are receiving as well such as ICU, Stepdown, or Med-Surg. I would have to give them an updated clinical information daily or every 3 days depending on the severity of illness. As a case manager, I was responsible for discharge planning and I preferred to transfer the patients to
In 2011, there were approximately 3.3 million readmissions to hospitals, raising healthcare costs and negatively impacting patient health. Two important contributors are discharge planning and education. Many patients do not receive enough of either, and are sent home misinformed about their diagnosis and medications. In order to decrease readmissions, hospitals should utilize interactive patient systems to educate patients while they are in the hospital. This will increase patient knowledge of their diagnosis, as well as make it easier for nurses to go over discharge teachings with the patient. This gives
Hwang, S.W., Chambers, C., Chiu, S., Katic, M., Kiss, A., Redelmeier, D.A., & Levinson, W.
The American Nurses Association supports a legislative model in which nurses are encouraged to create staffing plans specific to each unit. This approach will aide in establishing staffing levels that are flexible and can be changed based on the patients needs, number of admissions to the unit, discharges and transfers during each shift (“Nurse staffing plans,” 2013). This model will assist in keeping the unit staffed appropriately and organized in need of a change during each shift. Without an organized plan like this, a nurse may be required to take on a new admission and already have too big of a workload.
Ineffective discharge teaching often leads to unnecessary admissions to the hospital resulting in negative patient outcomes and decreased patient satisfaction. This negatively impacts the well-being of the patient and creates a financial burden on institutions. As a result, this universal practice issue requires a call to action on the part of the nursing profession. Nurses can proactively assist in assuring incidents of readmission do not occur. Nurses as educators play a critical role in the successful transition of patients from hospital to home. The overall goal of discharge education is to ensure there is an exchange of critical information between the patient and nurse in which plans of care are understood and followed. The research
The complexity and type of information, method of communication and caregivers of this program impact the effectiveness of the handoff and patient safety. Healthcare has evolved with time thereby becoming more specialized
Discharge planning is a routine feature of health in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmissions to hospital, to improve the co-ordination of services following discharge from hospital thereby bridging the gap between the hospital and community (S. Shapperd, 2008). The focus of this story is discharge planning that occurs while
A nurse’s typical day isn’t without stress; it is usually a lot of complex planning, critical thinking, time management, an abundance of communications with all departments of the hospital, and documenting events that have happened throughout the day on their entire patient assignment. “Nurses who are mandated following the completion of their regular shift are often ill-equipped to continue working. They have not planned for that situation with: proper advanced rest, arrangements for
Throughout the second half of the semester, I have not made any significant changes to my pre-clinical routine. I still prepare and gather my supplies the evening beforehand, and I try to avoid during schoolwork in order to facilitate restful sleep. However, upon arriving to the unit, I have developed a familiarity with the staff and environment that has reduced my stress and anxiety levels, allowing me to focus more attention on my patient assignment for the day. Although we do not have assigned preceptors, I have developed a mentoring relationship with two of the nurses on the unit and will work with those staff members if available. As we have gotten to know and trust one another, we do not have to spend the first part of our shift familiarizing ourselves,
Ineffective breathing pattern related to decreased oxygen saturation, poor tissue perfusion, obesity, decreased air entry to bases of both lungs, gout and arthritic pain, decreased cardiac output, disease process of COPD, and stress as evidenced by shortness of breath, BMI > 30 abnormal breathing patterns (rapid, shallow breathing), abnormal skin colour (slightly purplish), excessive diaphoresis, nasal flaring and use of accessory muscles, statement of joint pain, oxygen saturations of 85-95% 2L NP, immobility 95% of the day, and adventitious sounds throughout lungs (crackles) secondary to CHF, hypertension, pain caused by gout and arthritis, and obesity
Discharge planning and management with an elderly person can become very complicated and should be approached with an open mind and the willingness
Using the seven key principles of the hospital discharge process devised by the Department of Health (DH, 2003), this case study will critically analyse the process of an elderly patient who was discharged from a local acute trust. It begins by providing a definition of discharge planning, before providing a brief biography of the patient, including a rationale of why this patient was selected, details of her past medical history, reason for current admission, any issues raised and details of any care provided. Throughout this case study, in accordance with the Nursing and Midwifery Council (NMC, 2008) and the Data Protection Act (1998), the patient shall be referred to as Mrs. Blue to maintain anonymity. Although the