Understanding the difference between discharge arrangements and discharge planning is critical to a proactive Case Management model that begins upon initial contact with the patient and ends with the implementation of an informed, timely, and cost-efficient transition to the next level of care.

Discharge arrangements occur on the same day that the physicians’ discharge order is written. The services required at the time of discharge—home care, durable medical equipment, transportation, or alternate placement such as a nursing home or assisted-living facility—are started on the day the discharge order is written.

Discharge planning starts at admission. In the best-case scenario, a high-level screen is completed during the initial nursing assessment— including psychosocial and spiritual needs and financial concerns—to make referrals as needed. The Case Manager interviews the patient and family within 24 hours of admission to assess the current home situation and the potential barriers to discharge. The Case Manager works with the patient, the patient’s family, and the healthcare team, including the physician, to determine the anticipated discharge date and plan.

The goal of discharge planning is to create a patient-focused and patient-involved process that promotes active participation of the patient and family in post-acute discharge decisions. Additionally, the discharge plan helps the patient develop a workable, realistic care plan following discharge that is fiscally appropriate for patient, provider, and payer. The Case Manager follows up with the patient and family on a routine basis to verify the discharge plan and on the day prior to discharge, sets up the simple discharge planning tasks to avoid potential delays and delivers the Medicare Important Message.

Communication—both verbal and written—is key to a successful discharge. The initial patient interview allows for the early identification and management of patient needs. Furthermore, effective communication allows the Case Manager to…

• Educate the patient and family, helping them to select the appropriate discharge options.
• Make sure that the patient has the knowledge needed for post-discharge “self care” in order to alleviate anxiety and “unknowns.”
• Coordinate the discharge plan with the physician, healthcare team, patient, and family during the early phase of care to gain patient and family agreement.

Communication should occur among disciplines, patient and family, physicians, and with the post-hospital care providers to recognize and eliminate barriers to discharge and ensure the best outcome.

Why focus on discharge planning? A timely discharge increases patient, physician, and staff satisfaction, while decreasing length of stay, cost per case, and readmissions. Discharge planning ensures the facility’s compliance with Medicare Discharge Appeal Rights and patient choice for all providers such as home healthcare, skilled nursing facilities, and durable medical equipment, and it increases efficiency in accurate provisions of care, including compliance with Centers for Medicare and Medicaid Services and Joint Commission standards.

If your Case Management department is currently focusing primarily on Utilization Review and discharge arrangements, it may be time to consider a shift to Care Facilitation and Discharge Planning as a collaborative, interdisciplinary approach to patient throughput.

Compass Clinical Consulting can provide an assessment and recommendations to facilitate this change process at your organization. Contact our office at (513) 241.0142 or send us an email to discuss how to get started.