Reflective Essay On Discharge Planning

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

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

Standard 16 of the American Nurses Association (ANA) Scope and Standards Practice, directs nurse leaders to advocate not only for patients but for all members of our healthcare community. As a discharge planner, I am in a unique position to advocate not only for patients but for caregivers as well. As part of my responsibilities, I participate in daily multi-disciplinary team rounds. The meetings take place so that all disciplines can openly discuss patient care needs. They provide the perfect opportunity for anyone to bring to light problems or concerns.

The purpose of social institutions is to administer support to others in crisis situations in order to boast safety and stability. Social relations are the system structured to have needs met. Social work is more than helping but it’s a profession that provide services in assessing, intervening, research, and following best practices to improve conditions of society and advocate for social justice. The nature of social worker’s relationship and duties to their clients lies within the deontological theory. “The deontological theory states that people should adhere

The Robert Wood Johnson Foundation (2013) reports, “The U.S. healthcare system suffers from a chronic malady—the revolving door syndrome at its hospitals.” Currently, one of the many challenges hospitals face are increasing readmission rates. Various factors could contribute to the issue at hand. In this paper, the effectiveness of discharge planning will be explored to compare the efficiency of actual practice versus evidence-based practice research.

taught during residency). In particular, Dr. Chum noted that there was not a specific handbook or guideline that physicians were expected to follow in order to maintain quality of discharge among patients. It became clear that there was a lack of knowledge among various stakeholder parties on how the discharge process was managed for the patient. To address the issue, our project objective was to learn as much as possible about how current actors interacted to ensure a smooth discharge. Our method to meet this organizational goal is to conduct in-depth surveys about the various stakeholder parties associated with discharging patients. By interviewing key contributors to discharging patients, we can help Dr. Chum and Dr. Nieto better understand key actions being accomplished and possible pitfalls being overlooked.

Improve discharge process from hospital- improve communication and understanding of the discharge process with patient along with personnel dedicated to assisting through the transition

Student’s Role in Project: I was engaged in this project from the very inception and was involved in developing the project. In the developing phase of this project, patient needs, utilization, and costs were evaluated and two major priority needs areas were identified: non-emergent utilization of emergency department (ED) care and incomplete post-partum services, including well-baby visits. This project would help the discharge navigators connect with the frequent ED-utilizing and post-partum patients with a PCP and follow-up appointments. The goals of these discharge services are: (1) to minimize non-emergent use of ED services, thereby reducing cost and improving continuity of care with PCPs; (2) to ensure that pregnant patients schedule

Jacobson and Greenley (2001), states that this itself can be challenging as it is common for social workers to work collaboratively with involuntary individuals. Involuntary individuals or clients can refer to those who do not consent to treatment, do not ‘accept their diagnoses’ or is compelled to receive their treatment by the law (Lukens & Solomon, 2013). In regards to the recovery principles, in which individual choice and freedom is emphasised this can be both a contradiction as well as a dilemma for social workers (Lukens & Solomon, 2013).

During my placement, I also had difficulty with treatment planning. I struggled to find activities that were motivating and challenging for clients. Additionally my body language had not been clear to my supervisor and patients, making communication difficult. With one patient, this combination of communication and treatment planning difficulties may have left her unprepared upon discharge. C.D. was a 77 year-old female patient with End-Stage Renal Disease among other medical issues. She was new to dialysis, and went three times a week for the treatment. C.D. often stated she was too tired for therapy and required coaxing or encouragement to participate, particularly on the days she had dialysis treatment. She had not been using a mobility device prior to admission but had a rolling walker at home. I struggled to find meaningful occupations that would motivate her participation in

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.

The two learning objectives I have chosen for Tina’s discharge plan is falls prevention and recognizing signs and symptoms of hypoglycemia. I picked falls due to Tina stating she has always been clumsy and her foot injury occurred due to her falling on the stairs. In addition, Tina is going home on narcotics and crutches, which will increase her risks of falls. The second learning objective is recognizing and knowing what to do for hypoglycemia episodes. Although this is part of the bigger picture of diabetes, I believe that in order to achieve higher results we need to break apart the bigger picture and work on each aspect to ensure better understanding and compliance. Many times people find the big picture to be over whelming and they become

Discharge planning is a transition plan whose key objective is to provide a diabetes type 2 patient with self-management skills. A nurse or a physician can provide diabetes education. Proper education and good follow-up planning is imperative to post-discharge patients. Without it, up to 30% of patients with diabetes type 2 risk being hospitalized again within 30 days of discharge (Robbins & Webb, 2006). A good discharge plan is rational and well instituted; it retains the benefit of in-hospital insulin therapy when adapted to the patient's self-care. A discharge plan is formulated as a multidisciplinary collaboration of healthcare professionals who are involved in the care of diabetes type 2 patients. This provides a practical and ready-to-implement plan that is more likely to succeed.

It is not an easy process for people to just move on with their life when they experience such, it will take some time for them to recuperate by adjusting to the circumstance, and social workers are needed to help this population to try an overcome their fears, depression and anxieties.

The basic transpersonal insight that the full human potential includes empathy, creativity, and spirituality has been discussed by social workers since the inception of the profession (Canda, Chatterjee, and Robbins, 2012). This example is an application of transpersonal theory with individuals, families, groups, or communities. Definition of the helping situation is crisis. First, intake happens then comes presenting problem(s). In this example it is for intervention, next work with help recipient to achieve safety, explore meaning, and transformational potential. This leads to the question, has help recipient grown to higher level of self-actualization and transcendence (Yes). This leads to assisting help-recipient to integrate insights into daily life and social context. This leads to the question has help-recipient achieved higher level of functioning in social context (Yes). Finally, this leads to termination within ritual for celebration (Canda, Chatterjee, and Robbins,