Part Three: Case Management Boot Camp 2026: Fundamentals for Everyday Practice (ODPT3W6013)-Case Management Boot Camp 2026, Part Three Presentation

Case Management Boot Camp 2026, Part Three Presentation

Pdf Summary

This webinar reviews best practices for acute care discharge planning and the CMS Conditions of Participation (42 C.F.R. 482.43). It defines a discharge plan as the patient’s post-hospital destination, needed services, medication instructions, equipment, community supports, and financial resources. Hospitals are required to use an effective discharge planning process that is timely, patient-centered, and based on the patient’s goals, preferences, and caregiver involvement.<br /><br />Key CMS requirements include completing a discharge planning evaluation promptly, documenting it in the medical record, discussing results with the patient or representative, and updating the plan when the patient’s condition changes. The hospital must also regularly review discharge plans for effectiveness, including plans for patients readmitted within 30 days. For post-acute care referrals, hospitals must provide patients with a written choice list of participating providers, share relevant quality/resource-use data, and respect freedom of choice without steering patients to limited providers.<br /><br />The presentation emphasizes early discharge planning beginning at admission, interdisciplinary coordination, and strong handoffs to post-acute providers. Nurses and social workers share responsibility, with social work focusing on psychosocial needs and social drivers of health (SDOH) such as housing, food, transportation, safety, substance use, and finances. Tools such as standardized assessments, checklists, discharge time-outs, and transitional data sets are recommended to improve communication and reduce readmissions.<br /><br />It also reviews criteria and differences among discharge destinations such as home care, skilled nursing facilities, inpatient rehab facilities, long-term acute care hospitals, swing beds, hospice, and palliative care. Transportation planning, medication reconciliation, follow-up appointments, and post-discharge phone calls are highlighted as critical to safe transitions.<br /><br />Overall, the webinar argues that effective discharge planning improves patient outcomes, reduces avoidable readmissions, supports compliance, and ensures patients transition to the right level of care safely and on time.

Keywords

acute care discharge planning

CMS Conditions of Participation

42 C.F.R. 482.43

patient-centered care

post-acute care referrals

discharge planning evaluation

social drivers of health

medication reconciliation

readmission reduction

transitional care