Case Management

Checklist tool helps staff evaluate the entire patient, identify readmissions

Case Management Monthly, June 1, 2010

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Before implementing the Discharge Planning for Social Work Referral tool, Jennie Edmundson had a readmission rate of 8%. Despite its already low rate, increased regulatory focus on readmissions prompted Lorrie J. Reddish, RN, the hospital’s lead case manager, to  reevaluate the case management department’s understanding of readmissions. 

Reddish began by speaking with her staff.

“When I started talking to our case managers, everybody had a different idea of what was important to refer a patient to home health or a lower level of care,” she says. 

The differing opinions had a lot to do with which area of the hospital the case manager worked. New case managers also had different ideas of what factors could be a warning sign of a possible readmission. 

Reddish created the Discharge Planning for Social Work Referral tool using information from those conversations as well as information that was published in “Identifying Potentially Preventable Readmissions” in Health Care Financing Review, fall 2008. 

As the tool’s name suggests, patients identified as readmission risks are referred to a social worker, who then arranges for necessary postacute services (e.g., home health, skilled nursing, insurance applications). 

The result is a tool that helps case managers at Jennie Edmundson identify a patient’s readmission risk at the time the patient admits to the hospital and throughout his or her stay. 

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Case Management Monthly.

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