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

Video Transcription

Video Summary

This lecture focused on discharge planning as a complex, high-stakes hospital process that starts on admission and continues through transition to the next level of care. The speaker emphasized that discharge planning must go beyond choosing a destination; it should address patient goals, treatment preferences, medications, equipment, family support, transportation, community resources, and financial or psychosocial needs.<br /><br />A major theme was CMS requirements and best practices. Hospitals must complete timely discharge assessments, include caregivers as active partners, reassess patients regularly, document everything, and help patients choose post-acute providers using quality and resource-use data. The speaker explained choice lists for home health, SNFs, IRFs, and LTCHs, noting that managed care patients may have more limited provider options.<br /><br />The lecture also distinguished the roles of RN case managers and social workers, suggesting RNs focus more on clinical discharge needs while social workers handle psychosocial issues and social drivers of health. A “transitions case manager” role was also described for high-risk patients after discharge.<br /><br />Other topics included care transitions, handoffs, discharge checklists, transportation planning, home care and homebound criteria, palliative care, hospice, swing beds, SNFs, LTACHs, IRFs, PASARR, the MOON, IMM notices, and the three-day inpatient stay rule for Medicare SNF coverage. The speaker stressed that poor transitions can lead to readmissions, medication errors, and safety issues, so standardized processes and early planning are essential.

Keywords

discharge planning

hospital transition

care transitions

CMS requirements

post-acute care

case management

social workers

home health

skilled nursing facility

inpatient rehabilitation

long-term acute care

medication reconciliation

readmission prevention

transportation planning

hospice care