Case Management & Discharge

The given statement is true because the case manager actively assesses patients who are at risk of being readmitted to the hospital or require post-acute referrals. This assessment includes a thorough examination of the patient's medical history, medications, previous hospitalizations, consultant evaluations, test/procedure results, and input from the patient and their family. This proactive evaluation helps in identifying and addressing the needs of the patients, reducing the chances of readmission, and ensuring appropriate post-acute care.

An in-depth case management assessment is important because it helps healthcare professionals understand the patient's history and current response to treatment. This assessment also helps determine whether the services being provided are meeting the patient's needs effectively or not. Therefore, it is true that an in-depth case management assessment is basic to understanding the patient's previous and current response to treatment and how effective the utilization of services is in meeting the patient's needs.

Policy states that the case management assessment should be completed within 48 hours of admission.

An effective case management program can help reduce readmission rates, which can in turn help decrease healthcare spending. If 40% of hospitalized patients return within 30 days of discharge, implementing a case management program that provides follow-up care and support can help address the underlying issues that lead to readmissions. By providing patients with the necessary resources and assistance, they may be less likely to require readmission, ultimately reducing healthcare costs. Therefore, the statement "An effective case management program aids in reducing readmission rates" is true.

Any acute readmission would trigger a possible problem in the previous discharge plan. Evaluating cause of the readmission can give insight on where the problem [of transition] lies.

Discharge rounds are an important part of collaboration among the healthcare team and the sharing of information about the patient's response to the treatment plan. It is crucial that the discharge rounds include the patient's physical, mental, and behavioral status, as well as their progress and response to the treatment plan. These rounds should also reflect an interdisciplinary approach, involving various healthcare professionals. Additionally, it is important to discuss the patient's discharge readiness and determine the appropriate level of care they require, such as ICU, SDU, or RNF. Family gossip should not be included in the discharge rounds, and although the rounds are typically verbal, it is important to document the information discussed for future reference.

Timely and effective coordination of services is under the oversight of the case manger. He/she should address he anti -coagulation issue with the physician, and not rely on a note placed in the chart. the OT should be paged to address timely referral. The skilled nursing facility is responsible for obtaining the precertification, but the case manager ensures that the necessary referrals and information is forwarded to the patient's facility of choice.

The discharge assessment is current to the time it was made, and , should be updated throughout the hospital stay.