Part Three: Discharge Planning Workshop: Four-Part Webinar Series (ODPT3W5034)-Case Management Discharge Planning Workshop, Part Three Recording

Video Transcription

Video Summary

In this comprehensive webinar, Tony Sesta and Bev Cunningham discuss key aspects of discharge planning, access point case management, utilization management, levels of care, transitions of care, and transportation considerations within the healthcare continuum, emphasizing compliance with CMS regulations.<br /><br />They stress the importance of interdisciplinary discharge planning, involving patients and families from day one, to formulate safe, least restrictive discharge plans considering clinical and non-clinical resources. Different levels of care—acute inpatient rehab (IRF), subacute or skilled nursing facilities (SNFs), long-term acute care hospitals (LTACHs), swing beds, and home care—are explained with their criteria and challenges, such as therapy tolerances and medical necessity requirements.<br /><br />Access point case management, notably in emergency departments (EDs) and admissions/transfers, is highlighted as essential for appropriate level-of-care decisions, reducing denials, improving throughput, and enhancing patient satisfaction. The two-midnight rule guides inpatient versus observation status admission decisions, requiring physician documentation and collaboration to ensure compliance and proper billing.<br /><br />Recent CMS rules grant patients the right to appeal observation status after extended inpatient stays, adding complexity to utilization reviews. The importance of ongoing discharge planning, early intervention, and communication with post-acute providers is emphasized to minimize readmissions and optimize transitions.<br /><br />Transportation, increasingly recognized as a social determinant of health, must be assessed and planned for starting at admission to avoid delays, unsafe discharges, and missed follow-up care. EMTALA regulations govern medical screenings, transfers, and patient protections during transitions.<br /><br />Best practices include early, standardized, and patient-centered discharge planning with coordinated education, multidisciplinary collaboration, clear role definitions, and inclusion of caregivers—aimed at improving outcomes, reducing costs, and increasing patient satisfaction across the care continuum.

Keywords

Discharge Planning

Access Point Case Management

Utilization Management

Levels of Care

Transitions of Care

Transportation Considerations

CMS Regulations

Interdisciplinary Planning

Patient and Family Involvement

Acute Inpatient Rehab (IRF)

Skilled Nursing Facilities (SNFs)

Long-Term Acute Care Hospitals (LTACHs)

Two-Midnight Rule

Observation Status Appeals

EMTALA Regulations