What You Need to Know Before Leaving the Hospital
Linda Ziac, LPC, LADC, CEAP, CCM, CDP, CMDCP
Case Management & Advocacy | Case Management Expert
?“ Discharge Planning Aids Recovery & Reduces Readmissionâ€
There is a lot more involved in being discharged from the hospital, than just walking out the door.
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DISCHARGE PLANNING
The discharge planning process starts the first day the patient is in the hospital or rehab facility, and continues until the patient is officially discharged.
According to Medicare, discharge planning is “A process used to decide what a patient needs for a smooth move from one level of care to another.â€
The goal of discharge planning is to work with the patient and their family to create a plan that will identify the best level of care and services for a person after the patient leaves the hospital, while reducing adverse events and preventable readmissions.
Keep in mind that a patient may have arrived at the hospital from home, an assisted living facility, short term rehabilitation, or a long term care nursing home.
A discharge plan is unique and needs to be individually customized for each individual patient, with the hospital providing the patient with a written discharge plan and instructions.
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JUST THE FACTS
-?? 35 million hospital discharges take place in the US each year
-?? Unplanned readmissions to hospitals have a price tag of 15 - 20 Billion dollars annually
-?? 20% of Medicare patients discharged from the hospital are readmitted within 30 days
-?? 33% of Medicare patients are readmitted to the hospital within 90 days
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RESEARCH SHOWS
?? 20% to 30% of adverse events following discharge that lead to readmission, are preventable
?? Another 30% of these events, could at least be minimized
? Source: Medicare
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DISCHARGE PLANNING MEETING
Participants in the meeting usually include the patient, family members, and members of the patient’s care team (e.g. physician, nurse, physical therapist, social worker). Depending on where the patient resided prior to admission, participants may also include their primary care physician, the nurse from an assisted living facility, short term rehabilitation facility, or a nursing home; as well as any other persons deemed appropriate.
The purpose of the discharge planning meeting is to have an open discussion, and to review the patient’s:
-? Status and functional level before admission to the hospital
-? Current abilities, needs and wishes
-? Insurance benefit coverage
-? Medication review (e.g. discontinued meds, new meds, meds at time of discharge)
-? Next level of care needed (e.g. home with care, short term rehab, long term care)
-? What doctor(s) to see after discharge
-? Available care options (e.g. home with care, short-term rehab, assisted living, SNF)
-? Creation of an appropriate plan of action (care plan)
-? Clear understanding of the diagnosis, care plan, and follow up instructions
-? Selection and arrangements of providers for the next level of care
-? Putting as many pieces of the plan in place, before the patient is discharged
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DISCHARGE OPTIONS
-? Home with No Care
-? Home with Homecare Services
???? -?? Nurse
???? -?? Caregiver
???? -?? PT, OT, ST
-? Short Term Rehab at a SNF
-? Respite Care
-? Assisted Living Facility
-? Memory Care Facility
-? Long Term Care in a SNF
-? Hospice
This all may seem overwhelming at first, but if taken step by step, this process is very manageable and will help improve the patient’s health, safety and quality of life.
If you feel that this is too much to handle on your own, you can seek help from a professional such as an advocate, certified case manager, physician, or nurse.
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Please visit us at https://caregiverresourcecenter.com
Linda Ziac, LPC, LADC, CEAP, CCM, CDP, CMDCP
Founder/President
203-861-9833
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Photo from Microsoft
The information in this article is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information is not intended to be patient education, does not create any patient provider relationship, and should not be used as a substitute for professional diagnosis and treatment.
Please consult your health care provider for an appointment, before making any healthcare decisions or for guidance about a specific medical condition.
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Linda Ziac is a CT Licensed and Nationally Certified professional, with over 49 years of experience in the health and mental health field. In 1990, Linda Ziac had a vision of creating a place where seniors, people with special needs, and their loved ones could turn for support, find answers to their questions, and engage trained professionals to help them navigate the often confusing and overwhelming healthcare maze. Together, Linda works with the client, family, and healthcare staff to help assess and implement ways to allow for the client's greatest degree of health, safety, independence, and quality of life.
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