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CMW Tip of the Week: Evaluate patients' continuity-of-care needs

Case Management Weekly, October 15, 2008

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This week’s tip comes from Jackie Birmingham, RN, BSN, MS, CMAC.

It’s important to begin planning for a patient’s discharge as early as possible in his or her hospital stay, and one of the main steps for discharge planning is evaluating the patient’s continuing-care needs. Because all planning and intervention depends on it, the evaluation should be comprehensive and focused. General categories of evaluation should include the following:

• Current or recent health problems that are risk factors
• Level of consciousness (e.g., alert, semi-conscious, comatose)
• Cognitive behaviors (e.g., orientation, memory, judgment, depression)
• Functional status (e.g., basic activities of daily living like bathing, eating, transferring, and independent activities of daily living like using the phone, getting groceries, handling money)
• Communication (e.g., comprehension, expression, usual mode of communication)
• Environmental factors (e.g., barriers such as no home, no access to home, weather)
• Nursing and other care requirements (e.g., skilled care needs—type and amount, patient/family education)
• Family support (e.g., availability, ability, and willingness to accept responsibility)

Have a tip you’d like to share? Or maybe a question for our experts? Email it to editor Julie McGinley at jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!

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