Part Three: Discharge Planning Workshop: Four-Part Webinar Series (ODPT3W5034)-Discharge Planning Workshop Series, Part 3 Presentation

Discharge Planning Workshop Series, Part 3 Presentation

Pdf Summary

This comprehensive workshop, led by Toni Cesta, PhD, RN, FAAN, and Bev Cunningham, MS, RN, focuses on case management and discharge planning within acute care hospitals. It emphasizes the importance of interdisciplinary team collaboration, patient and family engagement, and education to ensure safe, effective transitions across the continuum of care—from hospital admission through post-acute services.<br /><br />Key highlights include detailed discussion of various care levels: inpatient rehabilitation facilities (IRFs) requiring intensive therapy; sub-acute care for less intensive rehabilitation or complex medical needs; skilled nursing facilities (SNFs) for daily skilled care post-hospitalization; long-term acute care hospitals (LTACHs) for patients with complex, serious conditions; and home care services critical for ongoing support. Case managers are the crucial link coordinating care and transitions across these diverse settings to reduce readmissions and enhance outcomes.<br /><br />The workshop also addresses admission and utilization management roles, particularly at access points like emergency departments (ED) and admitting/transfer departments. Emphasis is placed on medical necessity assessments, appropriate level of care determinations, and the "2-Midnight Rule" dictating inpatient versus observation status, including documentation requirements and exceptions. It introduces the upcoming right to appeal status changes from inpatient to observation for traditional Medicare beneficiaries, highlighting patient rights and hospital obligations, including the Medicare Change of Status Notice (MCSN).<br /><br />Transportation planning is underscored as vital for safe discharge and continuity of care, with cautionary examples illustrating risks from poor planning. Additionally, the workshop reviews EMTALA requirements ensuring emergency screening and appropriate transfers.<br /><br />In conclusion, it promotes best practices for discharge planning: early initiation, defined team roles, patient/family involvement, standardized processes, and coordinated follow-up care. These practices enhance patient satisfaction, reduce readmissions, and improve post-acute care quality, reinforcing case management's integral role in achieving seamless healthcare transitions.

Keywords

case management

discharge planning

acute care hospitals

interdisciplinary team collaboration

post-acute care

utilization management

2-Midnight Rule

Medicare Change of Status Notice

transportation planning

EMTALA requirements