Discharge planning has become more than just the movement of the patient out of the hospital. It is a “process” that starts at the point of admission and follow beyond discharge. The Centers for Medicare and Medicaid Services have recently added more “teeth” to the process with their updated Conditions of Participation.
As new case managers and social workers struggle with the challenge on more difficult transitions, it is critical that they understand key strategies to moving their patients through the continuum. Payer restrictions, gaps in the social determinants of health, homelessness and lack of family support are all challenges for both RN and social work case managers.
This module will review the updated changes to the Medicare Conditions of participation and is appropriate for both social workers and case managers in an acute care case management department. In addition, engagement with other members of the interdisciplinary care team will be reviewed, as the process of planning for the patient’s movement across the continuum occurs.
Transitional planning is no longer a destination but a process! Learn how to be sure that your processes address the complexities of the new healthcare environment.
Learning Objectives:
- Understand discharge planning as a process not an outcome
- Discuss the recent CMS changes related to transitional and discharge planning and how they can impact your practice
- Identify best practice strategies for transitioning patients across the continuum of care
- Differentiate the roles of RN case managers and social work case managers in the discharge planning process.
Areas Covered in the Session:
- Discharge planning process: As it is now and how it should be
- Barriers to effective discharge planning
- Transitions of care standards and expectations
- Rules and regulations for discharge planning, including critical access hospital rules and regulations
- The basics of discharge planning
- The discharge planning process
- RN case manager and social work case manager role differentiation
- Strategies for RN case managers and social work case managers
- Discharge planning and the managed care plan-both Medicare and Medicaid advantage plans
- The team effort in discharge planning
- Handoffs
- Did your plan work? Discharge planning outcomes
- Live Q&A Session
Suggested Attendees:
- Acute care RN case managers new to the role of ready for a refresher
- Acute care utilization managers
- Hospital case management leaders
- Physician Advisors (especially those new in the role)
- Acute care and long-term care RN case managers, critical access hospitals
- CFOs or executives responsible for case management
- Directors of Case Management
- Director of Finance
- RN Case Managers
- Directors of Social Work
- Directors of Compliance
- Discharge Planners
- Chief Medical Officers
- Case Managers
- Directors of Quality and Outcomes
- Social Workers
- Any Executive Responsible for Case Management
Presenter Biography:
Beverly Cunningham, MS, RN, ACM was most recently Vice President, Resource Management at a large acute care hospital. Her areas of responsibility included Case Management, Health Information Management, Patient Access, Solid Organ Transplant and Transplant Financial Services.
She has also been a Clinical Assistant Professor for the Master of Nursing Program at the University of Oklahoma, where she coached students in their clinical practicums. Bev is a well known speaker in the Case Management field. Involved in the development of case management for over twenty-five years, her areas of expertise include denials management, patient flow and the role of the Case Manager and Social Worker in the Case Management process. She has served as a Commissioner on the Commission for Case Management Certification and is a fellow with the Advisory Board. She has achieved ACM certification by the American Case Management Association. Bev’s publications include a chapter in CMSA’s third edition of Core Curriculum for Case Management Certification and most recently, co-author of the book, Core Skills for Hospital Case Management.
Bev has a BSN from Pittsburg State University, Pittsburg, Kansas and a Master of Science, Nursing Major, from the University of Oklahoma.
