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Educate the patient and family in plain language about the patient’s condition, the discharge process, and next steps throughout the hospital stay. Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s care to the patient and family and use teach back.
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Discharge planning involves a coordinated effort between the patient/resident, caregiving professionals, family members, and community supports. It is intended to smooth the transition from facility care to a home setting, or alternate facility.
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The aim of discharge planning is to reduce hospital length of stay and unplanned, unnecessary readmissions. The Role of the Discharge Planner. Provides education and support to the hospital staff in the development and implementation of discharge plans.
The goal of the IDEAL Discharge Planning strategy is to engage patients and family members in the transition from hospital to home, with the goal of reducing adverse events and preventable readmissions.
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Name the 5 key CMS standards in the Discharge Planning. Identify important education, equipment and discharge needs a COPD patient may need to be successful in managing their disease at home. Describe key roles in improving transitions.
Case managers focus on care coordination, financial management, and resource utilization to yield cost-effective, patient-centered solutions. They decide what the patient needs during a single episode of care. Case managers can play an especially important role in discharge planning for patients with more complex needs associated with an
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discharge. Case holders should identify what possible barriers may arise, and develop plans to address them. The persons strengths should be included as a means of furthering the successful discharge process. In addition, the persons natural support system should be included as well.
