August Referral to these services and supports should be the standard of care. Executive Summary The discharge planning worksheet that the Centers for Medicare & Medicaid Services developed for surveyors spells out what case managers should be doing to create an effective discharge plan. IDEAL #Discharge Planning Checklist. Discharge planning should begin as soon as possible. If not, whom should I call to make these appointments? Apply to Planner, Social Worker, Case Planner and more! Even simple measures help immensely. I began caregiving for my mother who has Huntington's disease about 2.5 years ago. Because people are in a hurry to leave the hospital or facility, itʼs easy to forget what to ask. As we have mentioned throughout this Fact Sheet, discharge planning is an inconsistent process that varies from hospital to hospital. What transportation arrangements need to be made? Ideally, and especially for the most complicated medical conditions, discharge planning is done with a team approach. Will someone come to my home to do an assessment to see if we need home modifications? This Fact Sheet will look at the keys to a successful transition from hospital to home, explain some important elements, offer suggestions for improving the process, and provide caregivers with checklists to help ensure the best care for a loved one. If you donʼt agree that your loved one is ready for discharge, you have the right to appeal the decision. Is someone available 24 hours a day and on weekends? endstream endobj startxref You should know that if the QIO rules against you, you will be required to pay for the additional hospital care. How can I get a respite (break) from care responsibilities to take care of my own healthcare and other needs. Of the 178 surveys return … Discharge planning and social work practice Soc Work Health Care. Studies have shown that numerous, and sometimes dangerous, errors can be made in home care when language is not taken into account at discharge. As caregiver, you are the “expert” in your loved oneʼs history. Is the building safe (smoke detectors, sprinkler system, marked exits)? Will we need a ramp, handrails, grab bars? Our Social Work & Patient Flow team is here to assist and support you in making plans for your discharge. It also should include information on whether the patientʼs condition is likely to improve; what activities he or she might need help with; information on medications and diet; what extra equipment might be needed, such as a wheelchair, commode, or oxygen; who will handle meal preparation, transportation and chores; and possibly referral to home care services. What medical conditions and limitations do I have that make providing this care difficult? Listed below are common care responsibilities you may be handling for your family member after he or she returns home: Community organizations can help with services such as transportation, meals, support groups, counseling, and possibly a break from your care responsibilities to allow you to rest and take care of yourself. Nurses, social workers, case managers, and other appropriate hospital staff can use this to aid discharge planning. A social worker. She had a very serious fall in 2013 and after being hospitalized for a few days her neurologist required her to have 24 hour care. Hospital social workers planning for discharge help inform patients when they will be going home and what they have to go through on the day of discharge. Medical Social Work. The whole process is performed by a professional discharge planner who develop the best plan for the patient. This checklist is designed to outline recommendations known to help in maintaining or establishing postpartum recovery. Keep careful records of your conversations. This is another good reason discharge planning should start early—as caregiver, youʼll have time to research your options while your loved one is cared for in the hospital. Who does it, when itʼs done, how itʼs done, what kind of follow-up is mandated, and whether caregivers are assessed for their ability to provide care and included as respected members of the discussion are all elements that differ from setting to setting. Will we get home care and will a nurse or therapist come to our home to work with my relative? Discharge planning through Valley's Care Coordination department and its team of case managers and social workers involves: Assessing your physiological, psychological, social and cultural needs You might not be giving much thought to what happens when your relative leaves the hospital. Tracking and analyzing data from your discharge planning checklists, patient well-being assessments, readmittance statistics, and other metrics can be a way to inform your discharge planning process and evaluate discharge programming. Discharge Planning and Outcomes Measurement A discharge planning checklist can give you a sense of how intensive recovery will be for a client and how much effort will likely be needed to ensure good outcomes. Pacific St., Seattle, WA 98195 | 206-598-4370 Discharge Planning Checklist Use this checklist as a guide for talking with your doctor and the rest of your health care team about what needs to be considered for your discharge. Finding those services can take some time and several phone calls. As a caregiver, you are focused completely on your family memberʼs medical treatment, and so is the hospital staff. A listing of all facts and tips is available online at https://www.caregiver.org/fact-sheets. How can I get a leave from my job to provide care? Will this medicine interact with other medications? Find inspiration for your hospital to undertake discharge … Medicare states that discharge planning is “a process used to decide what a patient needs for a smooth move from one level of care to another. An inmate’s discharge needs will be generally addressed 30–90 days prior to his or her release date. The few studies that evaluate patients with social work involvement in discharge Formally recognize the role families and other unpaid caregivers play, include them as part of the healthcare team, and assess their capabilities and willingness to provide care. Copyright © 1996–2020 Family Caregiver Alliance. Is the facility clean, well kept, quiet, a comfortable temperature? Does my family member require help at night and if so, how will I get enough sleep? Medical Social Work Standard Operating Procedure Template What Is Nursing Nursing Jobs Nursing Schools Nursing Assessment 90 Day Plan Lab Values Exam Guide. On the other hand, research has shown that excellent planning and good follow-up can improve patientsʼ health, reduce readmissions, and decrease healthcare costs. 101 Montgomery Street | Suite 2150 | San Francisco, CA 94104 | 800.445.8106 toll-free | 415.434.3388 local. What public benefits is my relative eligible for, such as In-Home Supportive Services or VA services? You may need to remind the staff about special care and communication techniques needed by your loved one. You may have very little time and little information on which to base your decision. What possible problems might I experience with the medicine? To examine the tasks involved in discharge planning and how frequently they are being performed, 124 Alabama hospitals were contacted with a 72% rcsponse rate. This fact sheet was prepared by Family Caregiver Alliance and reviewed by Carol Levine, Director, Families and Health Care Project, United Hospital Fund. You might simply be given a list of facilities, and asked to choose one. Fill in, initial, and date next to each task as completed. %%EOF Written materials must be provided in your language as well. endstream endobj 1029 0 obj <>/Metadata 51 0 R/Pages 1026 0 R/StructTreeRoot 138 0 R/Type/Catalog>> endobj 1030 0 obj <>/MediaBox[0 0 612 792]/Parent 1026 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1031 0 obj <>stream Why is this medicine prescribed? Studies have shown that as many as 40 percent of patients over 65 had medication errors after leaving the hospital, and 18 percent of Medicare patients discharged from a hospital are readmitted within 30 days. The social work intervention which contributes to effective discharge planning is evidenced by a social worker’s ability to manage patients’ continuing care needs at hospitals and in community-based health settings without recurring need for acute or emergent care services. In general, hospitals make money only when beds are occupied, so in many cases, discharge and transitional care planning become “orphan” services that produce no revenue. Do I know how to turn someone in bed so he or she doesn. Traditionally discharge planning has been conceptualized as helping patients make the transition from the hospital to the community. Discussions among experts on improving transitional care and discharge planning have centered on improvements that emphasize education and training, preventive care, and including caregivers as members of the healthcare team. This manual addresses Scope of Service, Job Descriptions and Competencies, Discharge Planning, Transfers, Social Service Guidelines, Case Management, Performance Improvement and much more! • Use the notes column to write down important information (like names and phone numbers). Private-Sector Hospital Discharge Tools. In that case, they will most likely determine the agency you use. Are hazards such as area rugs and electric cords out of the way? They will meet with you early in your admission, and discuss community support services and resources available to meet your post-discharge needs. The role of the hospital social worker in If a caregiver will be helping you after discharge, write down their name and phone number. With our graying population, these changes are ever more necessary. ABSTRACT Our work explores a brief historical development on discharge planning in hospitals and examines its significance in medical social work by considering the role of the hospital social worker. E-mail: [email protected] Medicare states that discharge planning is “a process used to decide what a patient needs for a smooth move from one level of care to another.” Only a doctor can authorize a patientʼs release from the hospital, but the actual process of discharge planning can be completed by a social worker, nurse, case manager, or other person. Medications need to be “reconciled,” that is, the pre-hospitalization medications compared with the post-discharge list to see that there are no duplications, omissions, or harmful side effects. Versus Usual care – no further FCA CareJourney: www.caregiver.org/carejourney Several pilot programs have illustrated those benefits, but until healthcare financing systems are changed to support such innovations in care, they will remain unavailable to many people. By Family Caregiver Alliance and reviewed by Carol Levine. They need your help. They will also advocate for appropriate services on behalf of the inmate. Family and friends also might assist you with home care. Broader recommended changes in practice and policy include: Multiple studies have explored the importance of effective discharge planning and transitional care, and have highlighted the very real benefits in improved patient outcomes and lower rehospitalization rates. Will insurance/Medicare/Medicaid pay for these? And although itʼs a significant part of the overall care plan, there is a surprising lack of consistency in both the process and quality of discharge planning across the healthcare system. For an effective discharge, the key principles acknowledge that it: 1. is not an isolated event, but a process that has to be planned soon after the admission, ensuring that both the patient and the caregiver understand and actively contribute to the planned decisions, as equal partners; 2. is facilitated by a comprehensive systematic approach that begins with the evaluation process; 3. is the result of an integrated MD team approach; 4. is organized by an operator who is responsible for the coordination of … In general, the basics of a discharge plan are: The discussion needs to include the physical condition of your family member both before and after hospitalization; details of the types of care that will be needed; and whether discharge will be to a facility or home. Reward hospitals and physicians that improve patient well-being and reduce readmissions to hospitals. Likewise, telephone calls from knowledgeable professionals to patients and caregivers within two days after discharge help anticipate problems and improve care at home. The list of questions below will give you direction as you start your search for a facility. • … base for determining whether social workers or nurses as discharge planners achieve better outcomes. 1028 0 obj <> endobj Part of that decision may be affected by whether the help will be “medically necessary” i.e., prescribed by the doctor, and therefore paid for by Medicare, Medicaid, or other insurance. Effective discharge planning can decrease the chances that your relative is readmitted to the hospital, and can also help in recovery, ensure medications are prescribed and given correctly, and adequately prepare you to take over your loved oneʼs care. Specific tasks which may be a part of the social worker's duties generally include but are not limited to: Marketing and providing tours for potential residents and families Planning for pre-admission and discharge Providing psycho-social assessment and completion of relevant parts of the social worker: If your hospital stay is planned, discharge planning can begin even before your admission. Will we need equipment such as hospital bed, shower chair, commode, oxygen tank? Will we need supplies such as adult diapers, disposable gloves, skin care items? For residents of the greater San Francisco Bay Area, FCA provides direct family support services for caregivers of those with Alzheimer's disease, stroke, ALS, head injury, Parkinson's, and other debilitating health conditions that strike adults. Write down a name and phone number of a person to call … As a part of this planning, the SNF must develop a discharge summary to help ensure that the resident’s care is … Formal appeals are handled through designated Quality Improvement Organizations (see the Resources section). The hospital must let you know the steps to take to get the case reviewed. Often this is the head nurse of your family member’s unit, who will coordinate any education regarding medications and other nursing issues. A nurse. How long is my relative expected to remain in the facility? You may have physical, financial, or other limitations that affect your caregiving capabilities. Make transitional care a Medicare benefit; change reimbursement policies to cover more home-based care in addition to institutional care. SNF DISCHARGE CARE PLAN MEETING CHECKLIST. As of August 16, 2019, we will no longer be selling or renewing individual subscriptions to our policy and procedure manuals. If the patient is being discharged to a rehab facility or nursing home, effective transition planning should ensure continuity of care, clarify the current state of the patientʼs health and capabilities, review medications, and help you select the facility to which your loved one is to be released. Social workers from 11 acute care hospitals in Israel provided data on 1426 discharged patients. Additionally, patients are released from hospitals “quicker and sicker” than in the past, making it even more critical to arrange for good care after release. Where do I get this equipment? Studies have found that improvements in hospital discharge planning can dramatically improve the outcome for patients as they move to the next level of care. Hiring In-Home HelpCaregivers Guide to Medications and Aging, Next Step in Care Is the home clean, comfortable, and safe, adequately heated/cooled, with space for any extra equipment? Does the facility have experience working with families of my culture/language? Think about both your needs as a caregiver and the needs of the person you are caring for, including language and cultural background. It is extremely important to tell hospital discharge staff about those limitations. Page 5 of 6 | Your Discharge Plan UWMC Social Work and Care Coordination | Box 356125 1959 N.E. Case managers should use the worksheet as a self-assessment tool to make sure they are complying with the CMS Conditions of Participation for discharge planning, according to an expert. Should this medicine be taken with food? How will our regular doctor learn what happened in the hospital or rehab facility? discharge plan with national guidelines, review of appropriate steps in an emergency, transmission of discharge summary to physicians and services, assessment of patient understanding, provision of a written discharge plan and telephone call from the pharmacist. A trip to the hospital can be an intimidating event for patients and their families. Coordinate care across sites, from hospital to facility to home. • The Social Worker will have knowledge of community resources and understand how to access the various agencies. Social workers can help you think things through and make arrangements for your special needs both during your stay and after you leave the hospital. In making your decisions, consider the following: home care agencies take care of all the paperwork for taxes and salary, substitutes will be available if the worker is sick, and you may have access to a broader range of skills. You may have other obligations such as a job or childcare that impact the time you have available. Social Work Department is available to assist patients of all ages and their families with their psychosocial and discharge planning needs. Will the insurance program pay for this medicine? The results revealed that the tasks performed typically resembled that of generalist social workers. At what point should I report these problems? Social Work/Discharge Planning (718) 302-8538 or (718) 963-7221. Discharge Planning process and includes a checklist that could be ... Physicians, nurses, discharge planners, social workers, and United Hospital Fund If that isnʼt enough, you will need to contact Medicare, Medicaid, or your insurance company. In an office, at home, somewhere else? SNFs must plan for the discharge of a resident when a discharge is anticipated to another care setting – another SNF, NF, ICF (for resident with mental retardation), a board and care home - or the resident’s home or other private residence. Strategy 4: IDEAL Discharge Planning (Implementation Handbook) Guide to Patient and Family Engagement . Is the location convenient? 2001;32(3):1-19. doi: 10.1300/J010v32n03_01. For example, sending the summary of care to the patientʼs regular doctor increases the likelihood of effective follow-up care. He or she also takes care of many details about rehab discharge. KATH’s discharge planning process includes an evaluation of the outcome of the patient’s treatment, a discussion between the social worker and the patient or a representative of the patient (a relative, friend or any other significant others) about the outcomes of the evaluation, planning, determination (how to execute the plan) and a referral (for when the patient is to be transferred to … There is also a scarcity of research on social work discharge planning outcomes (Preyde, Macaulay, & Dingwall, 2009). * Adapted with permission from www.nextstepincare.org, United Hospital Fund. Family Caregiver AllianceNational Center on Caregiving 2. Although both the American Medical Association and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) offer recommendations for discharge planning, there is no universally utilized system in US hospitals. At 2-week postdischarge, 407 patients and 659 family members evaluated the discharge planning process (information received, involvement, influence) and adequacy. Simplify and expand eligibility for public programs. Do residents have safe access to the outdoors? If you are a caregiver, you play an essential role in this discharge process: you are the advocate for the patient and for yourself. RESOURCES Community Housing Assistance Are there any foods or beverages to avoid? Improve training for healthcare staff, including ways to respond to language, culture, and literacy differences. Yet, the way this transition is handled—whether the discharge is to home, a rehabilitation (“rehab”) facility, or a nursing home—is critical to the health and well-being of your loved one. The Department is staffed with Licensed Social Workers who work in close collaboration with Physicians and other members of the multidisciplinary team to ensure safe transition from the Hospital. • Check the box next to each item when you and your caregiver complete it. Have these appointments been made? Through its National Center on Caregiving, FCA offers information on current social, public policy and caregiving issues, provides assistance in the development of public and private programs for caregivers, and assists caregivers nationwide in locating resources in their communities. 2. prescription and nonprescription? All rights reserved. Not all hospitals are successful in this. How does it work? Have I been given information either verbally or in writing that I understand and can refer to? What is adult day care and how do I find out about it? Are there special care techniques I need to learn for such things as changing dressings, helping someone swallow a pill, giving injections, using special equipment? ... McCroskey, Professor, School of Social Work, University of Southern California This manual was funded by a grant from The California Endowment. When specialization occurred, it was related to the populations served and not the specialized tasks or methods utilized. Since errors with medications are frequent and potentially dangerous, a thorough review of all medications should be an essential part of discharge planning. For example, you should have a telephone number(s) accessible 24 hours a day, including weekends, for care information. On the other hand, there may be a more personal relationship if you hire an individual directly, and the cost is likely to be lower. Family Caregiver Alliance (FCA) seeks to improve the quality of life for caregivers through education, services, research, and advocacy. While a bachelor’s degree in social work or nursing is the minimum requirement, many states mandate that certain kinds of discharge planners, such as those working in nursing homes, have at least a master’s degree in social work. Residents of such facilities are often elderly, and the social worker’s duties may be related to end of life planning or similar activities, according to the University of Iowa (ref 1). 1033 0 obj <>/Filter/FlateDecode/ID[]/Index[1028 19]/Info 1027 0 R/Length 49/Prev 384028/Root 1029 0 R/Size 1047/Type/XRef/W[1 2 1]>>stream This is not good for the patient, not good for the hospital, and not good for the financing agency, whether itʼs Medicare, private insurance, or your own funds. You have a choice between hiring an individual directly or going through a home care or home health care agency. You might be handed a list of agencies, with instructions to decide which to use—but often without further information. Ask about problems to watch for and what to do about them. h�b```"?���A�X��#�aT?�����*o�O�U��d�������ߐ��)��G\K(#���EP�q��m΅ *�Z4��:q���m��)�)���Z Can this medicine be chewed, crushed, dissolved, or mixed with other medicines? Your first step is to talk with the physician and discharge planner and express your reservations. Social Work Role in Discharge Planning . IDEAL Discharge Planning Checklist . Saved by NLM_4Caregivers. At a minimum, you have to be a licensed practical nurse or licensed social worker. What Is Discharge Planning? To help, a private geriatric care manager (for whom you will pay an hourly fee) or a social worker can offer much needed advice and support. The discharge staff will not be familiar with all aspects of your relativeʼs situation. Method: A prospective study. There are also online sources of information (see the Resources section of this Fact Sheet) that rate nursing homes, for example. Patient Name: Initial Nursing Assessment Prior to Discharge Planning Meeting During Discharge Planning Meeting Day of Discharge What services will help me care for myself? Where will the appointment be? Are there special facilities/programs for dementia patients? © 2009 Family Caregiver Alliance. Do I have transportation to get there? It is essential that you get any training you need in special care techniques, such as wound, feeding tube or catheter care, procedures for a ventilator, or transferring someone from bed to chair. • Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) about the items on this checklist. Are there things that are scary or uncomfortable for me to do, e.g., changing a diaper? What agencies are available to help me with transportation or meals? Nurse case managers and social workers are available to assist you and your family to make arrangements for post-hospital care. What health professionals will my family member need to see? Caregiving Across the States: 50 State Profiles (2014), Innovations in Alzheimer's Caregiving Legacy Awards, Caregiving for my mother who has Huntington’s disease. Despite its benefits, which clearly increase the well-being of patients and caregivers, discharge/transition planning is often not given the attention it deserves, and indeed, ineffectual planning often serves to add to patientsʼ and caregiversʼ stress. Under the best of circumstances, the discharge planner should begin his or her evaluation when the patient is admitted to the hospital. ��y40(w40p��e����� �L �m�����������`F}���&h{���P��O��N�v�5�~�b`�yHs2072��βH�2�޶ � �O ��A9 How will we know that the medicine is effective? While you may not be a medical expert, if youʼve been a caregiver for a long time, you certainly know a lot about the patient and about your own abilities to provide care and a safe home setting. Social workers function in a variety of work settings, one of which is the nursing home — also called a long term care facility. In either case, try to get recommendations for hiring from acquaintances, nurses, social workers, and others familiar with your situation. Kadushin and Kulys (1993) state that the provision of concrete services after discharge was the most basic, essential component and primary focus of discharge planning. 0 discharge. Social Work & Discharge Planning Social Work & Discharge Planning. Certain foods not allowed?). The discharge planner should be familiar with these community supports, but if not, your local senior center or a private case manager might be helpful. Are there means for families to interact with staff? Caregivers, patients, and advocates are continuing their efforts to alter our healthcare system to make discharge planning a priority. How do I get advice about care, danger signs, a phone number for someone to talk to, and follow-up medical appointments? Appendix B Mental Health: Discharge Plan Checklist ... situation or work to eliminate the crisis of homelessness. The discharge planners should discuss with you your willingness and ability to provide care. Convenience is a factor—you need to be able to easily get to the facility—but the quality of care is very important, and you may have to sacrifice your convenience for the sake of better care. Who pays for this service? Family Care Navigator: www.caregiver.org/family-care-navigator. Some of the care your loved one needs might be quite complicated. Too often, however, choosing a facility can be a source of stress for families. How many staff are on duty at any given time? %PDF-1.5 %���� From this data recommendations are made for linking advanced generalist social work practice to discharge planning activities. • … h�bbd``b`z$�AD4�`�?��Y&Y�d���� (415) 434-3388 | (800) 445-8106 Some studies have revealed that surprisingly simple steps can help. • Check the box next to each item when you and your caregiver complete it. If you need to hire paid in-home help, you have some decisions to make. How long the will the medicine have to be taken? Improve communication between hospital and community-based services. Can I begin the training in the hospital? A follow-up appointment to see the doctor should be arranged before your loved one leaves the hospital. Where can I find counseling and support groups? 1,200 Discharge Planner Social Worker jobs available on Indeed.com. The field also requires other professionals that offer patient care services to be involved in implementing the process. or herbal preparations that my relative is taking now? ` B)� Patients, family caregivers, and healthcare providers all play roles in maintaining a patientʼs health after discharge. • Use the notes column to write down important information (like names and phone numbers). Comprehensive information and advice to help family caregivers and healthcare providers plan transitions for patients. Initiated at admission by nurse discharge advocates. This person coordinates the discharge, making sure that everything happens when it should. Where do I get these items? Even without impaired memory, older people often have hearing or vision problems or are disoriented when they are in the hospital, so that these conversations are difficult to comprehend. You will need to check directly with the hospital, your insurer, or Medicare to find out what might be covered and what you will have to pay for. If you or your family member are more comfortable speaking in a language other than English, an interpreter is needed for this discussion on discharge. Develop better educational materials, available in multiple languages, to help patients and caregivers navigate care systems and understand the types of assistance that might be available to them, both during and after a hospital stay. If your loved one has memory problems caused by Alzheimerʼs disease, stroke, or another disorder, discharge planning becomes more complicated, and you will need to be a part of all discharge discussions. 1046 0 obj <>stream Website: www.caregiver.org Whom can I call with treatment questions? Unfortunately, these hiring decisions are often made in a hurry during hospital discharge. Ask the staff about your health condition and what you can do to help yourself get better. Do we need special instructions because my relative has Alzheimer, Eating (are there diet restrictions, e.g., soft foods only? We suggest you keep the questions summarized below (on pages 5–6 of the printout) with you, and request that the discharge planner take the time to review them with you. Spanish translations available.www.nextstepincare.org, Medicare's Nursing Home Comparewww.medicare.gov/nursinghomecompare, Medicare Rights Centerwww.medicarerights.org, Center for Medicare Advocacy "Hospital Discharge Planning"www.medicareadvocacy.org, Aging Life Care Association www.aginglifecare.org. Have I been trained in transfer skills and preventing falls? However, if something is determined by the doctor to be “medically necessary,” you may be able to get coverage for certain skilled care or equipment. • Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) about the items on this checklist. (See the Resources section at the end of this Fact Sheet.) Is there a less expensive alternative? Does the pharmacy provide special services such as home delivery, online refills, or medication review and counseling? You might not be aware that insurance, including Medicare, does not pay for all services after a patient has been discharged from the hospital. hެ�mO�0����}٤�&N&T�et�hj�: !d��fk�*1�����8$��¦��9w>���%\ �(�!�aB�h�A��1 B��p����NA�/*b�������h,�����xh��|���S�9��.�Y�x����:�w��Uq[�����fq��R_����?���� ����+������( d�DT"���FCi �%���65_��� �����8��_���4:�gE�R�:��{�ij��8U�>�8Z}3g1�R�'����,�`��g��ER⏺6;`4�㥚W�3.

discharge planning checklist for social workers

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discharge planning checklist for social workers 2020