Discharge Planning
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Communication is the Key to Ensuring a Successful Transition
In the hospital setting, the inpatient case managers should communicate amongst themselves, with the patient and family, and the nurse navigator, who, in turn, communicates with patients and everybody involved with them after discharge.
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Develop Criteria for Patients Referred to Complex Case Manager
Don’t base referrals to the complex case manager strictly on the age of the patient or the diagnosis.
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Coordinating Transitions Requires Experience, Knowledge of Resources
The role of transition coordinator may be a new one, but it will take an experienced case manager or social worker to handle it successfully.
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New Role for Case Managers Opens Up with Payment Reform
Somebody has to coordinate the post-discharge care now that hospitals are beginning to bear risk for what happens to patients after discharge, but inpatient case managers are already swamped and don’t have the time to do the job well, experts say.
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Sample List of Quality Measures Under Health Home Model
The New York State Health Home Program has a five-page list of goal-based quality measures collected to assess the program’s success.
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Here’s How Care Management and Care Coordination Work in NY
Typically, referrals to New York’s health home program are made by doctors, probation officers, or mental health clinics, although they could be made by any community organization or provider.
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Across New York, Organizations are Redefining Best Practices in Care Management
All across the Empire State, healthcare payers, providers, and community-based organizations have spent several years participating in a grand, national experiment of improving medical care for the highest-risk Medicaid enrollees.
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Is Your Case Management Department Making the Grade?
As a case manager or an administrator of a case management program in your organization, you may be called on to participate in the evaluation of the case management model, its effects on the organization, or its effects on patient outcomes.
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Get Ready to Give Your Patients the MOON
Hospitals should start now to develop a process to deliver the Medicare Outpatient Observation Notice (MOON), alerting patients that they are receiving observation services and informing them of their potential financial responsibilities.
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As Healthcare Becomes Value-based, Hospital Partners With the Community for Patient Care
Spartanburg (SC) Regional Healthcare System is partnering with providers at other levels of care and in the community to improve care for Medicaid patients and the uninsured.