Angel McGarrity-Davis, RN, CDONA, NHA

I’ve been hired at a long-term care facility as a care manager, and my entire background has been in case management from the acute care side. What in particular should I know about discharge planning?

In the Improving Medicare Post-Acute Care Transformation Act of 2014, there were additional proposed regulations added in November 2015 that pertain to discharge planning. 

When the right discharge planning is done, statistics show rehospitalizations are minimal.  

We also should think about patient-centered care and the needs of each patient when trying to assist in discharge planning.  Communication, coordination and education among each provider are necessary among all the providers. The more we work as a team, the better our quality of care will be.

Patients and their caregivers are not currently very involved in discharge planning. We have to empower the patient and family members to understand their specific disease process, understand their medications and also follow up with their physician in a timely manner.

To empower them we must first educate and communicate and then care coordinate. We need to know patients’ personal goals for their quality of life, which, as providers, we must realize might be different from what we think. 

A few areas to consider:

• Identify specific patient needs.

• Identify types of services that are available per the patient’s insurance. 

• Identify all other community resources available.  

• Discuss the issues, roles and responsibilities with the specific practitioners at each provider level.

• Don’t forget to distinguish who makes up your facility’s multidisciplinary team.