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Discharge Planning

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  • Best Practices for Hospital Z Codes

    Hospital Case Management asked Tammy Love, RHIA, CCS, CDIP, director of coding classification and policy at the American Hospital Association in Washington, DC, to answer a few questions via email about Z codes and what case managers need to know.

  • Large Medicare Data Study Shows Big Benefits with Primary Care Follow-Up

    New research shows Medicare patients who are hospitalized with a condition that could require emergency general surgery are far less likely to be readmitted if they receive follow-up care with a primary care provider within 30 days of discharge.

  • Standardized Care Protocols at SNFs Improve Hospital Readmission Rates

    New research shows how standardized care protocols can improve care and reduce readmission rates for patients with chronic conditions in skilled nursing facilities.

  • How the PSA Handoff Form Works

    The Patient Safety Attendant Handoff Form includes patient information and SBAR boxes for PSAs and nurses to communicate.

  • Nurses Develop Successful Handoff Tool for Patient Safety Attendants

    Nurse residents and co-investigators created and successfully tested a simple communication tool, called Patient Safety Attendant Handoff Form, that helps improve safety and care quality for patients with personal safety attendants.

  • Ensuring Compliance in Case Management Is Critical

    Many compliance issues in the CMS Conditions of Participation for utilization review and discharge planning need attention. Ensuring compliance is critical for improving patient care, preventing financial penalties or sanctions, and avoiding trouble with governmental authorities by identifying and correcting compliance issues early.

  • Consider the Burden for Those Caring for Older Trauma Patients

    Family caregivers of older people who have experienced a serious fall or another traumatic event sometimes are unprepared for the role. The authors of a recent study found close to one-third of family caregivers of older trauma patients experience high caregiver burden up to three months after the patient’s discharge.

  • Pandemic-Era Care Transitions Led to ED Overcrowding

    Researchers found that adult patients who visited EDs in a North Carolina health system between March 1, 2020, and March 1, 2022, faced significantly longer stays if they were transitioned from the ED directly to a skilled nursing facility (SNF) instead of transitioning to a hospital bed and then to a SNF.

  • Targeted Case Management Helps Patients Experiencing Homelessness

    The lack of affordable housing is a crisis affecting Americans in all age groups, in every city, in every state. Nearly half of Americans say finding affordable housing in their community is a major problem, according to Pew Research. A case management model in Philadelphia helps a local homeless population by connecting people with the healthcare they need as well as finding them stable housing.

  • Post-Acute Sepsis Care Needs Case Management-Style Help

    Case managers are well-positioned to help prevent rehospitalization of sepsis survivors by ensuring a smooth transition to post-acute care services. They can provide follow-up to ensure patients are receiving the home health services, therapies, and primary care visits they need.