The role of the hospital social worker in Fill in, initial, and date next to each task as completed. 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. 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 … The discharge planners should discuss with you your willingness and ability to provide care. FCA CareJourney: www.caregiver.org/carejourney You should know that if the QIO rules against you, you will be required to pay for the additional hospital care. At what point should I report these problems? As we have mentioned throughout this Fact Sheet, discharge planning is an inconsistent process that varies from hospital to hospital. Often this is the head nurse of your family member’s unit, who will coordinate any education regarding medications and other nursing issues. 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 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. Have I been trained in transfer skills and preventing falls? Will the insurance program pay for this medicine? You might not be aware that insurance, including Medicare, does not pay for all services after a patient has been discharged from the hospital. Are there things that are scary or uncomfortable for me to do, e.g., changing a diaper? Will we need equipment such as hospital bed, shower chair, commode, oxygen tank? Traditionally discharge planning has been conceptualized as helping patients make the transition from the hospital to the community. 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. ��y40(w40p��e����� �L �m�����������`F}���&h{���P��O��N�v�5�~�b`�yHs2072��βH�2�޶ � �O ��A9 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. Coordinate care across sites, from hospital to facility to home. 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. A social worker. What agencies are available to help me with transportation or meals? 2. E-mail: [email protected] How long the will the medicine have to be taken? discharge. 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 Family and friends also might assist you with home care. Can I begin the training in 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. Social Work Role in Discharge Planning . Family Caregiver Alliance (FCA) seeks to improve the quality of life for caregivers through education, services, research, and advocacy. There are also online sources of information (see the Resources section of this Fact Sheet) that rate nursing homes, for example. It is extremely important to tell hospital discharge staff about those limitations. The field also requires other professionals that offer patient care services to be involved in implementing the process. 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. Strategy 4: IDEAL Discharge Planning (Implementation Handbook) Guide to Patient and Family Engagement . You might not be giving much thought to what happens when your relative leaves the hospital. For example, sending the summary of care to the patientʼs regular doctor increases the likelihood of effective follow-up care. Are hazards such as area rugs and electric cords out of the way? Because people are in a hurry to leave the hospital or facility, itʼs easy to forget what to ask. 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. You might simply be given a list of facilities, and asked to choose one. All rights reserved. As caregiver, you are the “expert” in your loved oneʼs history. Is the facility clean, well kept, quiet, a comfortable temperature? 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. Saved by NLM_4Caregivers. h�b```"?���A�X��#�aT?�����*o�O�U��d�������ߐ��)��G\K(#���EP�q��m΅ *�Z4��:q���m��)�)���Z 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. Of the 178 surveys return … Discharge planning and social work practice Soc Work Health Care. RESOURCES Community Housing Assistance Think about both your needs as a caregiver and the needs of the person you are caring for, including language and cultural background. Likewise, telephone calls from knowledgeable professionals to patients and caregivers within two days after discharge help anticipate problems and improve care at home. They will also advocate for appropriate services on behalf of the inmate. August If a caregiver will be helping you after discharge, write down their name and phone number. This fact sheet was prepared by Family Caregiver Alliance and reviewed by Carol Levine, Director, Families and Health Care Project, United Hospital Fund. Have I been given information either verbally or in writing that I understand and can refer to? Should this medicine be taken with food? Social workers function in a variety of work settings, one of which is the nursing home — also called a long term care facility. 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. Discharge planning should begin as soon as possible. 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. 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. Is there a less expensive alternative? 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. Medical Social Work Standard Operating Procedure Template What Is Nursing Nursing Jobs Nursing Schools Nursing Assessment 90 Day Plan Lab Values Exam Guide. Ideally, and especially for the most complicated medical conditions, discharge planning is done with a team approach. Do I know how to turn someone in bed so he or she doesn. Simplify and expand eligibility for public programs. 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. What health professionals will my family member need to see? Unfortunately, these hiring decisions are often made in a hurry during hospital discharge. endstream endobj startxref 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. 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. This checklist is designed to outline recommendations known to help in maintaining or establishing postpartum recovery. 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. 101 Montgomery Street | Suite 2150 | San Francisco, CA 94104 | 800.445.8106 toll-free | 415.434.3388 local. Who pays for this service? Do residents have safe access to the outdoors? Website: www.caregiver.org • Use the notes column to write down important information (like names and phone numbers). Is the home clean, comfortable, and safe, adequately heated/cooled, with space for any extra equipment? Is the building safe (smoke detectors, sprinkler system, marked exits)? Where do I get these items? • Check the box next to each item when you and your caregiver complete it. The few studies that evaluate patients with social work involvement in discharge As a caregiver, you are focused completely on your family memberʼs medical treatment, and so is the hospital staff. 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. Find inspiration for your hospital to undertake discharge … 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: Under the best of circumstances, the discharge planner should begin his or her evaluation when the patient is admitted to the hospital. If your hospital stay is planned, discharge planning can begin even before your admission. The discharge staff will not be familiar with all aspects of your relativeʼs situation. How can I get a leave from my job to provide care? • … 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. United Hospital Fund Referral to these services and supports should be the standard of care. You might be handed a list of agencies, with instructions to decide which to use—but often without further information. Will insurance/Medicare/Medicaid pay for these? 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. 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. If you are a caregiver, you play an essential role in this discharge process: you are the advocate for the patient and for yourself. %%EOF If that isnʼt enough, you will need to contact Medicare, Medicaid, or your insurance company. If not, whom should I call to make these appointments? Make transitional care a Medicare benefit; change reimbursement policies to cover more home-based care in addition to institutional care. IDEAL #Discharge Planning Checklist. 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 How do I get advice about care, danger signs, a phone number for someone to talk to, and follow-up medical appointments? Social Work & Discharge Planning Social Work & Discharge Planning. This manual addresses Scope of Service, Job Descriptions and Competencies, Discharge Planning, Transfers, Social Service Guidelines, Case Management, Performance Improvement and much more! How will we know that the medicine is effective? 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. Apply to Planner, Social Worker, Case Planner and more! Studies have shown that numerous, and sometimes dangerous, errors can be made in home care when language is not taken into account at discharge. Finding those services can take some time and several phone calls. Some of the care your loved one needs might be quite complicated. 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. Keep careful records of your conversations. Patient Name: Initial Nursing Assessment Prior to Discharge Planning Meeting During Discharge Planning Meeting Day of Discharge Certain foods not allowed?). How can I get a respite (break) from care responsibilities to take care of my own healthcare and other needs. How long is my relative expected to remain in the facility? Is someone available 24 hours a day and on weekends? Improve communication between hospital and community-based services. On the other hand, research has shown that excellent planning and good follow-up can improve patientsʼ health, reduce readmissions, and decrease healthcare costs. Formal appeals are handled through designated Quality Improvement Organizations (see the Resources section). • Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) about the items on this checklist. 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). What services will help me care for myself? What public benefits is my relative eligible for, such as In-Home Supportive Services or VA services? With our graying population, these changes are ever more necessary. • Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) about the items on this checklist. • Use the notes column to write down important information (like names and phone numbers). 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. 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. %PDF-1.5 %���� 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. A trip to the hospital can be an intimidating event for patients and their families. 2. 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