Part Two: Discharge Planning Workshop: Four-Part Webinar Series (ODPT2W5034)-Case Management Discharge Planning Workshop, Part Two Recording

Video Transcription

Video Summary

In Part 2 of the webinar series on case management, speakers Bev Cunningham and Dr. Tony Sesta, both experienced consultants with Case Management Concepts, LLC, discuss regulatory requirements and best practices surrounding case management assessments, discharge planning, and transitions of care. They review Medicare and Medicaid conditions of participation, emphasizing early identification of patients at risk for adverse outcomes post-discharge and advocating for assessment ideally on the day of admission. Key standards include collaborative discharge planning involving qualified personnel like RN case managers and social workers, regular reevaluation of patient status, documenting discharge plans, and providing patients with quality data when selecting post-acute care providers. They highlight complexities with Medicare Advantage plans and emerging mandates requiring hospitals to share comprehensive quality metrics.<br /><br />The speakers stress the importance of coordinating patient transitions with clear communication and documented transfer protocols, including internal transfers. The incorporation of social determinants of health ("social drivers") into discharge planning processes is underscored as both a regulatory expectation and a factor affecting patient outcomes. Standardized assessment tools are recommended to streamline documentation, support referrals (e.g., to social work or home care), facilitate root cause analyses of readmissions, and include critical info such as treatment plans, social supports, and transportation needs.<br /><br />They advocate for optimized use of social workers focusing on psychosocial needs and RN case managers focusing on clinical care coordination. The session concludes with discussion of typical staffing ratios, challenges in managing readmissions, and reminders about upcoming resources and continuing education opportunities. Overall, the webinar offers a comprehensive update on case management regulations and practical strategies to improve discharge planning and reduce readmissions.

Keywords

case management

discharge planning

transitions of care

Medicare conditions of participation

Medicaid conditions of participation

early patient risk identification

assessment on admission

collaborative discharge planning

RN case managers

social workers

Medicare Advantage complexities

quality metrics sharing

social determinants of health

standardized assessment tools

readmission reduction strategies