Case Management

Mentor moment: Proactive discharge planning and collaboration with community resources leads to discharge without readmission

Case Management Weekly, March 24, 2010

The following article is adapted from HCPro’s resource for hospital case managers——a free blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices.

With so much happening in healthcare today, sifting through the complexity and knowing what to do and when is difficult. Healthcare professionals hear about proactive discharge planning, collaboration of care, transition to home, and preventing readmissions. But do we know how to put all these ideas together in the right sequence to improve quality of care?

Improved patient care starts with relationships. Hospital case managers and social workers must work with community home healthcare agencies, nursing and skilled nursing facilities, and insurance company utilization management resources. Let’s see how strong relationships help Mary Jo (MJ) as she progresses through an inpatient hospital stay.

Educating MJ

MJ is a 59-year-old female who works as an administrative secretary. She is married and has two grown children. MJ has insurance through her employer and has been in the hospital three times in the past seven months for recurrent exacerbation of her COPD. During this admission, MJ ’s case manager immediately begins to discuss discharge planning with MJ and during interdisciplinary rounds.

At the interdisciplinary rounds meeting, staff members note that MJ has never participated in pulmonary rehabilitation. The case manager also speaks with MJ’s insurance company and discovers she has benefits for pulmonary rehabilitation and home healthcare services. The social worker finds a local home healthcare agencywith a well established COPD disease management program. MJ is tired of being in the hospital and agrees to participate in the program.

The primary nurse speaks with MJ and discovers that no one has explained how MJ’s prescribed treatment will help her. MJ acknowledges that others have taught her the anatomy and physiology of her disease, but no one has told her why she must follow through with her treatments and what she can do to control her COPD.

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