CMSA Today - Issue 3, 2012 - (Page 18)
Acute Care Series
Does Discharge Planning Really Begin at Admission?
BY NANCY SKINNER, RNBC, CCM AND B.K. KIZZIAR, RNBC, CCM, CLCP
PART 3 of 3
n most acute care facilities, the concept of beginning discharge planning at the time of admission is more of a goal than a process; more an intent than an actuality and more ﬁction than veracity. Coordination of care as the patient moves through the health care continuum and discharge planning are both signiﬁcant mandates detailed within the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation as well as essential elements of Joint Commission Accreditation. CMS states that discharge planning evaluations must be completed in a timely manner so that appropriate arrangements for transitional care can be made prior to discharge. Joint Commission views the eﬀective coordination of transitional services as an essential safety practice and a vital component of necessary acute care services. Even with this direction and these mandates, all too often the plan to assist the patient in understanding all aspects of the treatment plan and acquiring the skills to execute that plan are provided in a last minute rush to discharge. If hospitals are to advance an enhanced promotion of patient safety across each transition of care and support the patient/ family/caregiver and the entire care completion team with the information and tools necessary to reach identiﬁed goals, the eﬀective and eﬃcient coordination of transitional services cannot be an afterthought. Although hospitals are considered the cornerstone of health care delivery, they are also viewed as “islands of excellence” with few bridges to connect that provision of excellent care to the community of providers who are dedicated to serving the patient/family/caregiver in all subsequent environments of care. In today’s environment of health care reform and value-based purchasing, case managers have become the one profession that has accepted
the role of bridging the patient from hospital to the next level of care with the necessary tools to succeed in that environment. Case managers have become the linchpins of care; joining patients, their support systems, and their caregivers to all services that are required to promote quality health care services through each transition of care. While case managers are at the epicenter of transitions of care, the roles and speciﬁc functions of case management vary from hospital to hospital with no consistency or agreement regarding job descriptions. Through the years, we have debated the speciﬁc responsibilities of the acute care case manager and, to date, we have not achieved consensus. But, we all can agree that eﬀective transitional care is vital to the health of the patient, the ﬁnancial health of the hospital, and the ultimate viability of the American health care delivery system. In order to advance eﬀective transitions, it is necessary to work collaboratively to support the development of all necessary steps associated with a transitional process. The following details a timeline for the delivery of transitional interventions that are required to assist hospitalized patients to be successful at the next level of care. The list is neither optional nor solely a function of case management. Each member of the patient-centered team has a role in facilitating completion of these essential functions. The one absolute responsibility of the case manager is conﬁrmation that all components of the transitional process were achieved.
DAY ONE DAY OF ADMISSION
• Assess transitional options during ﬁrst interview with the patient/family including a comprehensive assessment of support systems, home situation and previous living environment, ability to care for self, ﬁnancial and social barriers to care implementation as well as potential clinical needs. • Establish appropriate level of care. Utilization management is not necessarily a case management function but ensuring that objective criteria has been utilized to determine level of care is a necessary case management role. • Review the treatment plan to ensure the patient will be provided with the appropriate services without redundancies or unnecessary services.
In order to advance eﬀective transitions, it is necessary to work collaboratively to support the development of all necessary steps associated with a transitional process.
18 CMSA TODAY Issue 3 • 2012 • DIGITAL
Table of Contents for the Digital Edition of CMSA Today - Issue 3, 2012
The Art and Science of Integrated Case Management
Evidence-Based Practice Is an Art, Not Just a Science
Facilitating Change When Change is Hard-The Work of Professional Health & Wellness Coaches
Does Discharge Planning Really Begin at Admission? (Part 3 of 3)
The Massachusetts Revolution for a Resolution to Obtain MSL
CMSA Corporate Partners
Index of Advertisers
CMSA Today - Issue 3, 2012