Part Four Discharge Planning Workshop: Four-Part Webinar Series (ODPT4W5034)-Discharge Planning Workshop, Part Four Recording

Video Transcription

Video Summary

The final session of the webinar series on discharge planning began with introductions of Ms. Bev Cunningham and Dr. Tony Sesta, both experts in case management with over 25 years’ experience. The session emphasized that discharge planning is a complex, multi-step process involving admission assessment, determining the discharge destination, and ensuring safe transition with follow-up care. It requires participation from an interdisciplinary care team, including physicians, nurses, therapists, case managers, patients, and families.<br /><br />The presenters highlighted regulatory aspects such as the Conditions of Participation, the IMPACT Act requiring quality data reporting by post-acute care facilities, and Medicare rules including the three-day inpatient stay requirement for skilled nursing facility (SNF) coverage. They explained the use of detailed discharge notices and forms like the HIN-12 for patient appeals, and outlined new requirements emphasizing patient goals and preferences in discharge planning.<br /><br />Case studies illustrated challenges like patients refusing higher levels of care despite risks, families debating SNF choices, and integrating social determinants of health (e.g., access to food, transportation). The importance of early discharge planning — ideally at admission — was stressed for improving length of stay, patient satisfaction, and outcomes. Presenters recommended standardized discharge assessments and using quality data transparently to inform patients’ post-acute care choices.<br /><br />The session closed with discussion of community resources to support social drivers of health, the value of interdisciplinary collaboration, and practical tips for navigating insurance authorizations. Participants were encouraged to engage with ongoing education and to reach out with questions to reinforce best practices in ensuring safe, patient-centered discharge transitions.

Keywords

discharge planning

case management

interdisciplinary care team

Conditions of Participation

IMPACT Act

Medicare rules

skilled nursing facility

patient appeals

discharge assessments

social determinants of health

early discharge planning

community resources

insurance authorizations