Discharge Planning
RSSArticles
-
Project ECHO Reduces Readmissions, Shortens SNF Length of Stay
The Project Extension for Community Healthcare Outcomes connects multidisciplinary skilled nursing facility teams with a multidisciplinary hospital team via videoconferencing. The program effectively reduces patient readmissions and skilled nursing facility length of stay. -
Case Study Shows Positive Results of Intensive Care Coordination
For one client, care coordination assistance through a Transition to Success framework helped her go from being homeless to housed within 86 days. -
From Homelessness to Self-Sufficiency, Case Management-Style Program Works
Case managers increasingly recognize the importance of addressing social determinants of health among patients across the care continuum, but evidence-based interventions are scarce. One new program seeks to change this with tactics to address one of the most prevalent social determinants of health: Poverty. A novel care transition and community case management program provides an evidence-based standard of care to treat poverty as an environmentally based and treatable condition.
-
Many Ethics Consults Involve ‘Unbefriended’ Patients
Most unrepresented patients are living with marginal housing and psychiatric comorbidity in addition to cognitive decline and medical illness. It is helpful to engage in dialogue among inpatient clinicians and outpatient providers, case managers, and social workers. Working together, these groups can facilitate a transition from inpatient care to the community and provide input on options for housing.
-
Using EMR Data to Identify Patients at Risk of Frequent ED Visits
Case managers are at an advantage when they can make informed decisions from electronic medical record data and other sources. One way they can use the data is by identifying patients who might be at risk of frequent emergency department visits. -
Case Management at the Entry Points: Ensuring Reimbursement Through Appropriate Surveillance
At a time when capacity and reimbursement are more important than ever, case managers play a key role in helping operations run smoothly. One way this happens is through monitoring the entry points of the hospital. These points include the emergency department, post-anesthesia care unit, direct admission to the units, or transfers from other facilities. This is not to say case managers should now add “security guard” to their extensive list of roles and tasks; rather, they are uniquely positioned to survey the whole picture, including how entry points are used. -
Maintaining Case Management Certification
The world of case management continues to evolve. Those who have been along for the ride over the past few decades have seen quite a bit of progress. One of those areas of advancement is certification. While not every case manager is board-certified, the prospect of certification is a hot topic and a worthwhile endeavor. -
Beta-Blockers and Case Management Help Reduce Readmissions of Heart Failure Patients
Ninety-day mortality and readmission rates are significantly lower for older patients with heart failure and reduced ejection fraction when they receive a beta-blocker after hospitalization. Case managers also can reinforce the provider’s information about common medication side effects and what issues and changes they should look for. -
Case Management Depending More on Advanced Practice Nurses
Advanced practice nurses (APNs) are becoming case managers as part of a trend fueled by the growth of managed care. APNs helping with care coordination can contribute to improved quality of care and communication at discharge and reduce readmissions. -
Hospitals in States Without Medicaid Expansion Face Discharge Challenges
States that have expanded Medicaid under the Affordable Care Act reported fewer hospitalizations for uninsured acute ischemic stroke patients than states that did not expand Medicaid.