Social Work Discharge Plan

Patients recently discharged from acute care back to the community are at an increased risk for hospital re-admission (3). Efficient collaboration between interdisciplinary health professionals and nurse liaison can improve discharge planning processes.

If she returns home, what considerations need to be taken into account as part of her discharge plan? Using your local area, research and present the needed or preferred community resources (macro) that would be available to them. Critique the ability of these community resources to adequately meet the needs of this diverse family’s circumstances.

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).

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

The main theme identified in this research focused on the Hospital readmission rate that has gained increasing attention because it reflects the effectiveness of healthcare system performance and the quality of patient care. The five articles studied all highlighted that an effective discharge planning is crucial to improve continuity of care between hospital and home/elderly home so as to improve patient’s health and reduce patient readmission. The themes that emerged described discharge planning in the hospital as pivotal in the continuing care of people who are in need of medical, social and rehabilitation care. Additionally as the needs of patients increase and become more complex, it is also important that an effective discharge planning system should have the capacity to discriminate and respond to different levels of need for coordination and post-discharge care (Central, 2012).

to request that she meet with this writer to discuss her current counseling non-compliance status and how she is refusing to schedule an individual session. Counselor told her that she signed a notice of counseling non-compliance letter and if she failed to schedule an individual session by 1/22/16, she faces possible a discharge from the AMS program. Pt. agreed to schedule an individual session by stating, “I’m going to schedule something tomorrow. I’m sorry. I got a lot on my mind.”

PO is referred to continue chemical dependence treatment at the community agency. PO will need to have a new assessment to determine appropriate level of care. PO is recommended to attend minimally of two self-help meetings per week, abstain from all mood-altering substance, and utilize positive support structure to aim and maintain substance free lifestyle.

This officer has had contact via face to face and phone with the mother, Ms. Evelyn Edwards. Discussions have taken place with her regarding Marquel’s Comprehensive Re-Entry Case Plan. She has participated in a video conference with Marquel since his commitment. She is aware of his placement in the Virginia Beach CPP Program. She has not visited him at the facility, but she has had contact with him via phone. She is currently unemployed. Upon Marquel’s release from DJJ, the anticipated parole plan (CRCP) will be for him to return to her home with intensive supportive services via 294 funding. Additionally, in the event this placement is no longer available, an alternative placement will be sought via 294 funding for a group home placement or

Consent: The child and family team is in agreement that Out of Home Treatment is an appropriate treatment option for the youth at this time due to youth behaviors that lead to numerous arrests and violation of probation. Youth needs to address his mental health, substance use and behavioral issues in the community and in the home by engaging in safe behaviors. The youth has demonstrated a lack of impulse control, oppositional behavior towards rules and regulations of the home, school, and community prior to DAP Bed. The program noted Dre’quan has been staying out of trouble and requested for youth to continue with treatment at Florence Klemmer House/DAP Bed. CM was informed Dre’quan refuse to comply with chores rules. Dre’quan shared his experiences

The NMC Code (2008) charges nurses to protect confidential information, and to only use it for the purposes given – for their treatment. Therefore all patients and events mentioned in this essay are inspired by real patients and events, but names, locations, dates and other details have been altered or obscured to make identification impossible. Following the introduction of the knowledge and skills framework (DH 2004a) and emphasis on quality of health care and patient centred, interprofessional, health and social care (DH 2000; Leathard 2003; Thompson et al. 2002) health care professionals and students will need to be able to

| Some medications need to be taken on an empty stomach, where others need to be taken with food. Sometimes patients stop taking medication because they don’t know what the side effects are, so they think that it’s not helping them. Some side effects may not feel right, but the medication is still helping you and you should continue to take them as prescribed. If you feel like you can’t take them you should consult your physician before stopping them.

As a community social services assistant, I work directly with pediatric patients that have been discharged from St. Vincent Hospital. When meeting with patients post discharge, I have noticed that they are often confused about the types of services they require. I have considered various options to address this issue and have come up with a potential solution. Hospital admissions can be overwhelming for young children; I am suggesting we trial providing homecare information in a more fun and less intimidating manner. I am suggesting we hire a popular local clown named Claris who performs at children’s parties .Claris is passionate about helping children, and would be able to explain homecare information in a fun and interactive way that would be easier for children to understand.

Plan of action: Client must attend to all offsite and onsite medical appointments, Client must participate in all FEDCAP/Wellness programs, client must participate in all scheduled meetings, client must accept first suitable housing offers, client must adhere to the shelter 10pm curfew. Client must notify staff of any changes in her income. CM reviewed the Other ILP Review. Client agreed and signed. Next ILP Review is scheduled for

What does your state law say regarding public hospitals and discharging patients who do not have a place to go?

I currently do the readmissions and discharge assessment and planning in the orthopedic department. This unit consists of 36 private rooms. Most commonly the procedures are hip fractures (total hips) and elective hip and knee replacements, sometimes a shoulder or ankle fracture. Average length of stay for non-hip/knee would be 2- 3 days. We do receive medical overflow patients as well. It is important to know that while we as nurses are in the business of caring, our workplace is just that; a business. And the owners are in this business want to make money. The increase in patient volume require a precise nurse to patient ratio to provide safe and effective care and stay within the budget.