Part Three: Basics of Case Management, Five-Part Series-Basics of Case Management Series, Part 3 Recording

Video Transcription

Video Summary

In today's session, Dr. Tony Sesta, a founding partner of Case Management Concepts, LLC, addressed the complexities and current practices in discharge and transitional planning in healthcare settings. She emphasized that discharge planning, once perceived as simple, is now more intricate, particularly with the Centers for Medicare and Medicaid Services (CMS) introducing social drivers of health. Dr. Sesta underscored the importance of beginning discharge assessments from day one to avoid unnecessary delays in patient transitions, which impact length of stay and healthcare costs. Emphasizing a holistic approach, she discussed the need for a comprehensive evaluation that includes patient and family considerations, medication adherence, and the use of community resources.<br /><br />The session elaborated on the regulatory framework guiding discharge planning, notably the CMS conditions of participation, recent updates from the 2019 final rule, and the IMPACT Act's influence on post-acute care. Dr. Sesta advocated for an interdisciplinary approach where the entire care team contributes to the discharge plan, considering a patient's clinical and social needs.<br /><br />She also differentiated between discharge planning and transitions of care, underscoring the importance of effective handoffs to ensure patient safety and continuity of care. Handoffs should be standardized with both verbal and written communication to minimize errors and readmissions. Various issues like family dynamics, reimbursement variations, and ineffective communication across care providers were highlighted as challenges in discharge transitions.<br /><br />Furthermore, Dr. Sesta outlined strategies for effective patient transitions, including post-discharge follow-up phone calls, community resource connections, and addressing end-of-life issues early. She concluded with discussions on care settings like acute rehabilitation, subacute care, skilled nursing facilities, and home care, providing criteria for selecting appropriate post-discharge environments. Throughout, she encouraged leveraging policies and advocacy for patient-centered, compliant discharge planning.

Keywords

discharge planning

transitional planning

healthcare

CMS

social drivers of health

patient transitions

length of stay

healthcare costs

holistic approach

regulatory framework

IMPACT Act

interdisciplinary approach

patient safety

communication

post-discharge