Part One: Discharge Planning Workshop: Four-Part Webinar Series (ODPT1W5034)-Discharge Planning Workshop, Part One Recording

Video Transcription

Video Summary

This webinar, presented by Ms. Bev Cunningham and Dr. Tony Sesto of Case Management Concepts, LLC, provides a comprehensive overview of hospital-based case management with a focus on discharge and transitional planning. Both experts bring over 25 years of experience and emphasize the complexity and critical importance of effective discharge planning as part of overall hospital operations, especially in light of increased scrutiny from the Centers for Medicare and Medicaid Services (CMS).<br /><br />Key roles of hospital case managers include patient flow management, utilization and resource management, denial management, avoidable delay management, quality management, discharge planning, and psychosocial assessments and interventions. Patient flow ensures timely and coordinated care transitions throughout the acute care continuum, aiming to minimize delays and optimize length of stay. Utilization management focuses on ensuring medically necessary services are provided in the most appropriate setting, while resource management addresses the appropriate use of hospital resources to control costs and prevent over- or under-utilization.<br /><br />Denial management involves proactively handling payer reimbursement issues, and avoidable delay management targets identifying and resolving factors that prolong hospital stays unnecessarily. Quality management ensures that patient care meets established standards with attention to safety and successful outcomes. Discharge planning is an interdisciplinary, collaborative process beginning at admission that assesses patient needs, aligns with patient goals and treatment preferences, and coordinates appropriate post-acute care to reduce preventable readmissions. Psychosocial interventions, typically led by social workers, address social determinants of health impacting discharge success.<br /><br />The webinar stresses the importance of integrated teamwork between RN and social work case managers and the value of standardized processes, documentation, effective communication, and inclusion of family caregivers in planning and transitions. It highlights challenges such as varying physician practice patterns, payer regulations, staffing limitations, and coordination with post-acute providers. Transitional care is defined as the active movement of patients across settings, with emphasis on safe, seamless handoffs supported by evidence-based standards.<br /><br />The presenters encourage early, ongoing assessment, interdisciplinary rounds, and collaboration with community resources, post-acute providers, and family caregivers. They underscore the need for data-driven leadership, use of clerical support to maximize licensed staff efficiency, and innovative roles like transitions case managers for follow-up after discharge. Overall, effective discharge and transitional planning are essential for patient safety, satisfaction, compliance with CMS regulations, and cost containment in healthcare delivery.

Keywords

hospital-based case management

discharge planning

transitional planning

patient flow management

utilization management

resource management

denial management

avoidable delay management

quality management

psychosocial assessments

interdisciplinary collaboration

post-acute care coordination

CMS regulations

transitional care

case manager roles