Case Management

Sneak peek: How can discharge planning prevent readmissions?

Case Management Weekly, March 3, 2010

by June Stark, RN, BSN, MEd

The handoff of patients from the hospital to another care provider is a critical transition. Success of the discharge and preventing readmission often are dependent on the best practice components included in the handoff.

Many case managers see things only from the perspective of their own hospital setting. Case managers should communicate with caregivers in the receiving setting prior to discharge to better understand the patient’s needs at the next level of care.

Case managers should consider meeting with each care provider who represents the patient’s transition alternatives, including home care, SNFs, long-term care facilities, and even the receiving family members. These meetings can help hospital-based case managers better understand the needs of newly discharged patients and caregivers.

For example, if a patient requires a complex medication regimen, the caregiver in the home or receiving facility may need more than clearly written discharge medication orders. Caregivers might appreciate a complete description of the hospital medication course, including:

  • The plan for transitioned setting 
  • The last three laboratory values reflecting medication effectiveness 
  • The physician’s contact information 
  • Contact information for other nurses or case managers

Check out the March 2010 issue of Case Management Monthly to learn more. You also can discover the benefits of becoming a Case Management Monthly subscriber.

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