Last week, in Part One, I talked about the Discharge Planning Process. In Part Two, I wanted to continue the discussion and expand on how effective discharge planning can improve outcomes regardless of your setting
Areas covered in part one:
- Emphasize early communication with the facility team
- Highlight family involvement and education
- Address safety, mobility, home setup, equipment, and transportation
- Medication reconciliation and follow-up care
- Reinforce that discharge planning is ongoing, not a one-time event
Now, let’s focus on specific responsibilities for the Case Managers have when someone is injured or ill and preparing for discharge
- Are there return-to-work barriers that need to be addressed before discharge with the patient?
- If the person cannot work, find out if they have a disability policy and recommend that they activate it. If they don’t have a personal policy, they may have a policy from their employer. Having a disability policy allows the person to get paid for lost time.
- Ensure the insurance carrier has the supporting documentation to authorize home health, DME, transportation, and diagnostic testing to move the case forward.
- If the person was not injured at work, recommend that the patient talk to his/her employer to let them know they cannot work. Ask whether there is any modified-duty or transitional work based on their restrictions.
- Obtain the patient’s job description that the treating physician will need to it determine readiness to return to work.
Communication and documentation are critical in case management. What needs to be documented before discharge?
- Are there restrictions that the person must be aware of? What does it mean for a safe discharge?
- Who needs to be notified ( Primary Care Doctor, any specialists, therapy team, the patients’ employer, their managed care company, so they make sure follow-up care is in network).
- Will an insurance company case manager be assigned? Doing these things will ensure care is coordinated. If not, who should the patient follow up with?
- Communicate changes in the plan or new needs to the patient and their family so they are prepared to go home.
Psychosocial and Emotional Readiness
- How is the patient coping emotionally with the transition home?
- Do they show signs of fear, anxiety, depression, or lack of confidence? This is especially important in catastrophic or long-term cases.
- How is the family coping?
Consider Social Determinants of Health.
The patient may be the family’s breadwinner and just making it week to week on their salary; now, being injured and unable to work, can cause stress and anxiety and affect the injured worker and their family in many ways.
What if the patient does not have health insurance? How will they access care?
Does the patient/family have food security?
Is there reliable electricity for equipment?
Are there financial barriers to transportation or caregiving?
These factors can derail what we thought would be a safe discharge.
Caregiver Burden
Is there a caregiver to assist the patient if he/she is unable to do simple ADLs?
Is the caregiver physically and emotionally able to provide the required level of care? If not, assistance may be needed, like going to rehab or an assisted living program, until the person can manage on their own.
Caregiver Burden is real and a major safety factor. Please make sure you don’t overlook it, as it can cause readmissions, setbacks, and exacerbations due to complex conditions.
Red Flags After Discharge
What symptoms or changes should prompt a call to the provider?
When should the injured worker go to the ER?
Educating the patient and family to prepare them for treatments, equipment, and challenges that may arise from their injury or illness.
Keeping these tips in mind helps tie the clinical discharge plan back to the real-life world people (patients and families) come from.
I hope this article is helpful. Please share Part One and Part Two with your teams. Add them in accordance with your organization’s policy and procedures.
Let me know if you have any questions or comments.
Have a good week!
