The proposed changes to the Conditions of Participation for Discharge Planning will likely have profound effects on how case management departments organize their work. It will also affect the workloads of RN case managers and social workers. Patients in ambulatory settings such as out-patient surgery, outpatient procedures and emergency departments will all need to be assessed for the purpose of creating a discharge plan. Family caregivers and physicians will be expected to be much more involved than they have in the past. Case management departments will be expected to follow patients via phone calls as they transition out to the community.
This program will review the current rules and regulations from the Conditions of Participation for discharge planning. We will then discuss the most recent changes from the Medicare program and how they will impact the roles of the RN case manager and the social worker. We will review strategies for safely transitioning your patients across the continuum of care. In addition to that, we will review how to engage other members of the interdisciplinary care team in the process of planning for the patient’s movement across the continuum including verbal and written hand-off communication. We will also discuss the positive impact that effective discharge planning processes can have on hospitals, post-acute providers and patients!
Learn how to be sure that your processes address the complexities of the new healthcare environment and that your role as a case manager or social worker is designed and staffed to meet the changes ahead!
Case managers and social workers are the drivers of the discharge planning process. Transitional and discharge planning have become more than just the movement of the patient out of the hospital. They encompass a “process” that starts at the point of admission and follows the patient beyond discharge. The Centers for Medicare and Medicaid Services (CMS) have recently added more “teeth” to the process as it is outlined in the Conditions of Participation for Discharge Planning. Discharge planning is no longer a destination but a process that starts before the patient is admitted to the hospital and continues after they are discharged
Toni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and evaluating acute care and community case management models, with an eye on structure, process and outcome measures for nurse case managers and social workers.
The author of nine books, and a frequently sought after speaker, lecturer and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management. Among her books are included the “The Case Managers Survival Guide” and “Core Skills for Hospital Case Managers”.
Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management newsletter in which she shares insights and information on current issues and trends in case management. She is a past commissioner for the Commission for Case Management Certification. She has held positions as Senior Vice President, Corporate Vice President, Director of Case Management and professor of case management.