FUNCTION: Continuum of Care TITLE: Discharge Planning: Assessment, Implementation and Coordination ______________________________________________________________________________ PURPOSE: 1. To establish a mechanism which fosters admission screening for each patient to determine potential needs. 2. To implement low risk and high risk screening criteria, which identify patients meeting those criteria. 3. To establish a mechanism for continued education of all staff involved in patient care, as it relates to discharge planning. 4. To assist patients and their families with the social, emotional, and environmental problems which may accompany or be related to illness. 5. To provide guidelines for assisting patients and/or their families with arrangements necessary for post hospital care to include home health care, durable medical equipment needs, homemaker service, long-term nursing care, and rehabilitation, etc. 6. To facilitate the processing of referrals to Community Agencies, homemaker service, and assessment of home environment. To facilitate the proper and efficacious discharge of a patient. POLICY: 1. To establish interdisciplinary communication through the use of forms, patient conferences and participation in interdisciplinary discharge planning conferences. 2. Include the patient, family, care givers, and significant others in the design and implementation of the discharge plan. a. The patient and family make the final decisions concerning the aftercare of the patient. b. If the recommended discharge plan is refused, the physician and the respective staff member is notified, and the patient or family's refusal is documented. An acceptable safe alternative is presented, if applicable. c. Patient safety is the ultimate goal of discharge planning, but decisions are not made that conflict with the patient's rights. 3. Ensure comprehensive documentation of the essential patient information within the medical record and to organizations, and facilities receiving referrals. 4. Maintain a current knowledge of regulatory and accrediting body standards and/or directives. 5. Establish a referral list of resources. 6. Develop and implement continued education of the staff, as it relates to the process of discharge planning. 7. Provide continual evaluation of the program. GENERAL GUIDELINES: 1. Staff is responsible for counseling and emotional support, and the discharge planning process (which includes nursing home placement, arranging for home health care or medical equipment, as well as for information about and referral to community resources and agencies when appropriate). As the patient's advocate, the case manager/social worker is available to act as a liaison between the patient and the institution and help to humanize the hospital experience for the patient and his/her family. 2. Referrals can and should come from all levels of staff, as well as from the individual patients and families themselves. Early referral of patients with problems can improve the quality of services provided. The staff is available to intervene with patients at high social risk, for crisis intervention, and for those whose illness will necessitate an adaptation in lifestyle. High risk can include those with life-threatening disease, those are to have or who have had disfiguring surgery, and long term patients who may be depressed or anxious in the hospital environment. 3. Assessment for discharge needs and/or psychosocial risk is done by the nurse upon admission to the unit and referral is made to case management via Meditech. A social work/discharge planning assessment is performed by case manager/social worker upon initiation of discharge planning. 4. Prior to the patient's discharge, the Case Manager/Social Worker/Nursing staff, confirms the receiving facility's acceptance of the patient. To ensure the continuity of care, the receiving facility will be updated on appropriate patient information. Such information includes, but is not limited to, reason for discharge, current physical and psychosocial status, summary of care and services, progress towards achieving goals and instructions or referral provided. 5. In addition, the case manager/social worker provides a specific channel for handling patient's problems and dealing with complaints, risk potential and needs not met. 6. The case managers' office is located on the first floor next to the Health Information Management Department. The Social Workers office is on the first floor next to the admitting office. Office hours are 0800 to 1630, or by appointment. During these hours, there will be at least one member of the department in the facility. After hours and on weekends and holidays, a staff member is on call for emergencies only and can be reached through the nursing supervisor. A calendar on a month by month basis will be provided to the House Supervisor. Situations that constitute an emergency include: a. Child/elderly abuse. b. Rape victims c. Victims of crime d. Those to be seen at the House supervisor's discretion. 7. Routine referrals will be sent to the Case Manager/Social Worker via Meditech, telephone, or in person and responded to within 24 hours or one working day. 8. The names, pager numbers and extension numbers of the Case Managers and Social Worker are in the Meditech Library designated for that purpose. 9. Discharge planning may also be performed by designated agents via approved contractual arrangements. 10. Documentation of discharge planning or social services shall be timely, appropriate, concise to reflect the current patient status and pertinent psychological, social, and financial information. The notes communicate information about discharge arrangements, family situation, living arrangements, and other problems as are pertinent to the care of the patient. The documentation is found in the nursing admission assessment (augmented by additional assessments in specialty units), case manager notes, physician progress notes, or special records. HIGH RISK GROUPS: 1. Age a. 70 or older, living alone or with a non-capable care-giver. b. Mentally retarded, regardless of age. c. Patients transferred from or anticipating transfer to nursing homes, residential care home or speciality hospital. d. Patients appearing neglected or abused, regardless of age. 2. Residence a. Patients with illegal alien status. b. Readmissions (less than 7 days) due to noncompliance, absence of caregiver, etc. c. Patients with environmental problems (dilapidated and/or rodent infested environment). d. Patient's with no address or home. 3. Behavioral a. Attempted suicide or suicidal tendencies. b. Suspected substance abuse. c. Behavioral problems or coping deficits. d. History of noncompliance with the health care plan. e. Multiple readmissions 4. Social a. No known family or next of kin. b. Dysfunctional family characteristics which affect patient's treatment and post hospital care. c. No known supportive systems. d. Victims of crime. e. Patient unable to return to preadmission living arrangements. f. Patient resides with disabled family member. g. Patient with inadequate financial resources h. Victims of suspected child abuse/elderly abuse 5. Medical a. Multiple trauma, i.e. motor vehicle accident, assault, burn patients. b. Head and spinal cord injuries. c. Handicapped - visual, hearing, paralysis, comatose, or any other debilitating conditions. d. Chronic conditions, - chronic obstructive lung disease, congestive heart failure, end stage renal disease, or any other conditions that may impair the patient's functional status. e. Total joint replacement. f. Terminal illness - metastatic cancers, end stage congestive heart failure, AIDS, respiratory or cardiac arrest. g. Drug overdose. h. Change in treatment: new medications, new insulin or new need to monitor blood sugar, new diet, new tubes (trach, central line, PEG), potential home IV therpay (including antibiotics) open wound care or monitoring. i. Change in patient's functional status. j. Communicable disease: sexual, tuberculosis, hepatitis 6. Social Services a. Patients in need of follow-up treatment, teaching and/or referral to other agencies (home care, day care/nutrition site, etc.) b. Patients with inadequate financial resources. c. Patients requiring special equipment in the home (bedside commode, wheelchair, hospital bed, etc). d. Patients who have a change in their functional status. e. Patients requiring supportive care - transportation, housekeeping, sitters. f. Patients requiring emotional support as determined by nursing, physician, family members, chaplaincy or others having knowledge of the patient. g. Transfer from or anticipated transfer to a nursing home, rehabilitation or specialty hospital, or residental care home. DISCHARGE PLANNING PROGRAM GOALS PURPOSE: 1. To maximize patient potential for recovery with resolution of health care and related needs. 2. To provide care plan development to meet established patient specific criteria. 3. To focus the plan of care and services on the patient, family, identified needs and established goals. 4. To maintain a patient advocacy to ensure selection of resource utilization based on patient preferences. 5. To provide facility and community resource information for patients and families to make realistic choices regarding post hospital care plans and to facilitate the implementation of the established plan. 6. To foster interdisciplinary communication and understanding of the patient and family in relation to his/her medical and psychosocial environment. 7. To provide a system for communication, documentation, team development and re-evaluation of the patient, taking into consideration the anticipated needs at the present level of health care delivery and thereafter. 8. To utilize current, cost effective, quality resources with continual monitoring of patient services. 9. To guarantee professional growth of those involved in the delivery of health care, as related to discharge management and patient care. 10. To assure high quality standards of practice through a continual evaluation process. 11. To promote inter-agency collaboration and coordination to achieve continuity of care and utilize health care resources more effectively. 12. To provide a consistent method of patient care management, which maximizes the hospital length of stay, thereby decreasing risks of readmissions related to non-compliance and inappropriate utilization of resources. 13. To build a continuum of care between the acute care facility and community alternative and providers. 14. To promote high quality patient care which identifies early in the episode of care those patients at risk for discharge planning barriers or with the potential for extended lengths of stay related to inadequate resources, alternatives, or support system. 15. To maximize use of the health care facilities resources internally and externally. 16. To ensure compliance with discharge planning standards as defined by the regulatory and accrediting bodies. 17. To develop a systematic approach, which provides a formal and coordinated discharge management approach. 18. To communicate with hospital administration, medical staff, nursing and other departments as necessary to provide the patient with the most cost effective and best use of facility and community resources available. PROCEDURES A. Referral for Long-Term Care (Nursing facility) and Rehabilitation 1. Case manager/social worker assesses home environment, family and financial needs for long term care or rehabilitation. This includes discussion with physician, nursing personnel and patient and family. 2. Assesses skilled or non-skilled criteria or rehabilitation criteria for nursing home placement or to a rehabilitation facility to include federal criteria/regulations and State financial criteria as appropriate. 3. Patient/family is provided with various options including nursing home bed availability according to Federal guidelines or specific insurance coverage. 4. Once the decision is made, the case manager/social worker/nursing staff facilitates discharge to the nursing facility or rehabilitation facility and provides the receiving facility with appropriate patient information to ensure the continuity of care. Such patient information includes, but is not limited to reason for discharge, current physical and psychosocial status, summary of care and services, progress toward achieving goals and instructions or referrals provided. 5. When it is indicated the case manager/social worker will complete the 3652 form for the State Medicaid program for the nursing facility. Home Health Care/Durable Medical Equipment 1. The case manager/social worker will assess the need for home health care services and/or durable medical equipment (DME) through discussing the patient's medical condition with the physician and nursing staff. 2. The case manager/social worker will meet with the patient and/or family to assess the home situation and discuss what assistance may be necessary and/or available. 3. The case manager/social worker will provide information regarding insurance coverage of these services. 4. The home health agency and/or DME agency will be chosen per patient, physician or insurance company preferred provider arrangements. If there is no preference, the patient will be given a choice of appropriate home health/DME agencies. 5. The patient and/or family will be notified of arrangements and will be provided written information containing the agency's name and phone number. The physician will be notified of arrangements through chart documentation. 6. When the patient is discharged, case management or nursing staff will notify the nursing agency of discharge and will communicate to the receiving health care facility appropriate patient information that will ensure continuity of care. Such patient information includes, but is not limited to reason for discharge, current physical and psychosocial status, summary of care and services, progress towards achieving goals and instructions or referrals provided. 7. The case manager/social worker will advise family to contact agency if problems arise. If problems cannot be resolved, the family and patient are instructed to contact the case managers/social worker for further assistance. B. Referral to Community Agencies 1. The case manager/social worker will assess the need for referral to community agencies and/or homemaker service through consultation and/or interview with the patient, his/her family, nursing staff and physician. Assessment will include discussing the patient's medical condition, home situation and financial status. 2. Worker will determine the type of services that would benefit the patient. 3. The patient and/or family is given a list of appropriate agencies with phone numbers, or makes referral directly, if appropriate. 4. Follow-up is provided as necessary. C. Home Environmental Evaluation 1. Assessment is made through interviewing patient, family, significant others, and community agencies who are involved. 2. Case manager/social worker may contact an outside agency, which has the capability to evaluate the patient's home environment. 3. The information obtained will be reported to the physician and an appropriate plan of care will be formulated, based on the findings.