A nurse. In an office, at home, somewhere else? Are hazards such as area rugs and electric cords out of the way? Patients, family caregivers, and healthcare providers all play roles in maintaining a patientʼs health after discharge. If not, whom should I call to make these appointments? Studies have shown that as many as 40 percent of patients over 65 had medication errors after leaving the hospital, and 18 percent of Medicare patients discharged from a hospital are readmitted within 30 days. What health professionals will my family member need to see? On the other hand, research has shown that excellent planning and good follow-up can improve patientsʼ health, reduce readmissions, and decrease healthcare costs. SNFs must plan for the discharge of a resident when a discharge is anticipated to another care setting – another SNF, NF, ICF (for resident with mental retardation), a board and care home - or the resident’s home or other private residence. Spanish translations available.www.nextstepincare.org, Medicare's Nursing Home Comparewww.medicare.gov/nursinghomecompare, Medicare Rights Centerwww.medicarerights.org, Center for Medicare Advocacy "Hospital Discharge Planning"www.medicareadvocacy.org, Aging Life Care Association www.aginglifecare.org. Under the best of circumstances, the discharge planner should begin his or her evaluation when the patient is admitted to the hospital. When specialization occurred, it was related to the populations served and not the specialized tasks or methods utilized. Will we need supplies such as adult diapers, disposable gloves, skin care items? As a caregiver, you are focused completely on your family memberʼs medical treatment, and so is the hospital staff. From this data recommendations are made for linking advanced generalist social work practice to discharge planning activities. Comprehensive information and advice to help family caregivers and healthcare providers plan transitions for patients. The field also requires other professionals that offer patient care services to be involved in implementing the process. You have a choice between hiring an individual directly or going through a home care or home health care agency. Website: www.caregiver.org Family Care Navigator: www.caregiver.org/family-care-navigator. 2001;32(3):1-19. doi: 10.1300/J010v32n03_01. RESOURCES Community Housing Assistance In that case, they will most likely determine the agency you use. Written materials must be provided in your language as well. Will the insurance program pay for this medicine? Will we need a ramp, handrails, grab bars? On the other hand, there may be a more personal relationship if you hire an individual directly, and the cost is likely to be lower. Have these appointments been made? Is the facility clean, well kept, quiet, a comfortable temperature? You might be handed a list of agencies, with instructions to decide which to use—but often without further information. base for determining whether social workers or nurses as discharge planners achieve better outcomes. Ask about problems to watch for and what to do about them. Will insurance/Medicare/Medicaid pay for these? Ideally, and especially for the most complicated medical conditions, discharge planning is done with a team approach. It is extremely important to tell hospital discharge staff about those limitations. Case managers should use the worksheet as a self-assessment tool to make sure they are complying with the CMS Conditions of Participation for discharge planning, according to an expert. Think about both your needs as a caregiver and the needs of the person you are caring for, including language and cultural background. 1046 0 obj <>stream h�b```"?���A�X��#�aT?�����*o�O�U��d�������ߐ��)��G\K(#���EP�q��m΅ *�Z4��:q���m��)�)���Z It is essential that you get any training you need in special care techniques, such as wound, feeding tube or catheter care, procedures for a ventilator, or transferring someone from bed to chair. Are there things that are scary or uncomfortable for me to do, e.g., changing a diaper? You may have physical, financial, or other limitations that affect your caregiving capabilities. Social Work/Discharge Planning (718) 302-8538 or (718) 963-7221. 2. ��y40(w40p��e����� �L �m�����������`F}���&h{���P��O��N�v�5�~�b`�yHs2072��βH�2�޶ � �O ��A9 If the patient is being discharged to a rehab facility or nursing home, effective transition planning should ensure continuity of care, clarify the current state of the patientʼs health and capabilities, review medications, and help you select the facility to which your loved one is to be released. 2. You may need to remind the staff about special care and communication techniques needed by your loved one. I began caregiving for my mother who has Huntington's disease about 2.5 years ago. Because people are in a hurry to leave the hospital or facility, itʼs easy to forget what to ask. Apply to Planner, Social Worker, Case Planner and more! Family Caregiver Alliance (FCA) seeks to improve the quality of life for caregivers through education, services, research, and advocacy. Family Caregiver AllianceNational Center on Caregiving • Check the box next to each item when you and your caregiver complete it. Social Work Department is available to assist patients of all ages and their families with their psychosocial and discharge planning needs. Is the location convenient? Who does it, when itʼs done, how itʼs done, what kind of follow-up is mandated, and whether caregivers are assessed for their ability to provide care and included as respected members of the discussion are all elements that differ from setting to setting. However, if something is determined by the doctor to be “medically necessary,” you may be able to get coverage for certain skilled care or equipment. Private-Sector Hospital Discharge Tools. FCA CareJourney: www.caregiver.org/carejourney The role of the hospital social worker in The discharge planners should discuss with you your willingness and ability to provide care. Is someone available 24 hours a day and on weekends? The list of questions below will give you direction as you start your search for a facility. h�bbd``b`z$�AD4�`�?��Y&Y�d���� All rights reserved. Nurse case managers and social workers are available to assist you and your family to make arrangements for post-hospital care. Certain foods not allowed?). They need your help. At a minimum, you have to be a licensed practical nurse or licensed social worker. While a bachelor’s degree in social work or nursing is the minimum requirement, many states mandate that certain kinds of discharge planners, such as those working in nursing homes, have at least a master’s degree in social work. Listed below are common care responsibilities you may be handling for your family member after he or she returns home: Community organizations can help with services such as transportation, meals, support groups, counseling, and possibly a break from your care responsibilities to allow you to rest and take care of yourself. Several pilot programs have illustrated those benefits, but until healthcare financing systems are changed to support such innovations in care, they will remain unavailable to many people. Medical Social Work Standard Operating Procedure Template What Is Nursing Nursing Jobs Nursing Schools Nursing Assessment 90 Day Plan Lab Values Exam Guide. Keep careful records of your conversations. What medical conditions and limitations do I have that make providing this care difficult? Social workers can help you think things through and make arrangements for your special needs both during your stay and after you leave the hospital. Tracking and analyzing data from your discharge planning checklists, patient well-being assessments, readmittance statistics, and other metrics can be a way to inform your discharge planning process and evaluate discharge programming. Broader recommended changes in practice and policy include: Multiple studies have explored the importance of effective discharge planning and transitional care, and have highlighted the very real benefits in improved patient outcomes and lower rehospitalization rates. What Is Discharge Planning? Will this medicine interact with other medications? 1,200 Discharge Planner Social Worker jobs available on Indeed.com. How do I get advice about care, danger signs, a phone number for someone to talk to, and follow-up medical appointments? This is not good for the patient, not good for the hospital, and not good for the financing agency, whether itʼs Medicare, private insurance, or your own funds. • Use the notes column to write down important information (like names and phone numbers). Will we need equipment such as hospital bed, shower chair, commode, oxygen tank? Ask the staff about your health condition and what you can do to help yourself get better. Some of the care your loved one needs might be quite complicated. 1033 0 obj <>/Filter/FlateDecode/ID[]/Index[1028 19]/Info 1027 0 R/Length 49/Prev 384028/Root 1029 0 R/Size 1047/Type/XRef/W[1 2 1]>>stream Where will the appointment be? For an effective discharge, the key principles acknowledge that it: 1. is not an isolated event, but a process that has to be planned soon after the admission, ensuring that both the patient and the caregiver understand and actively contribute to the planned decisions, as equal partners; 2. is facilitated by a comprehensive systematic approach that begins with the evaluation process; 3. is the result of an integrated MD team approach; 4. is organized by an operator who is responsible for the coordination of … What transportation arrangements need to be made? How can I get a respite (break) from care responsibilities to take care of my own healthcare and other needs. Nurses, social workers, case managers, and other appropriate hospital staff can use this to aid discharge planning. Copyright © 1996–2020 Family Caregiver Alliance. Will we get home care and will a nurse or therapist come to our home to work with my relative? Does the facility have experience working with families of my culture/language? We suggest you keep the questions summarized below (on pages 5–6 of the printout) with you, and request that the discharge planner take the time to review them with you. For example, sending the summary of care to the patientʼs regular doctor increases the likelihood of effective follow-up care. How will we know that the medicine is effective? KATH’s discharge planning process includes an evaluation of the outcome of the patient’s treatment, a discussion between the social worker and the patient or a representative of the patient (a relative, friend or any other significant others) about the outcomes of the evaluation, planning, determination (how to execute the plan) and a referral (for when the patient is to be transferred to … At what point should I report these problems? Does my family member require help at night and if so, how will I get enough sleep? With our graying population, these changes are ever more necessary. In general, the basics of a discharge plan are: The discussion needs to include the physical condition of your family member both before and after hospitalization; details of the types of care that will be needed; and whether discharge will be to a facility or home. They will meet with you early in your admission, and discuss community support services and resources available to meet your post-discharge needs. And although itʼs a significant part of the overall care plan, there is a surprising lack of consistency in both the process and quality of discharge planning across the healthcare system. You might not be aware that insurance, including Medicare, does not pay for all services after a patient has been discharged from the hospital. 0 Effective discharge planning can decrease the chances that your relative is readmitted to the hospital, and can also help in recovery, ensure medications are prescribed and given correctly, and adequately prepare you to take over your loved oneʼs care. At 2-week postdischarge, 407 patients and 659 family members evaluated the discharge planning process (information received, involvement, influence) and adequacy. A follow-up appointment to see the doctor should be arranged before your loved one leaves the hospital. He or she also takes care of many details about rehab discharge. If your hospital stay is planned, discharge planning can begin even before your admission. In general, hospitals make money only when beds are occupied, so in many cases, discharge and transitional care planning become “orphan” services that produce no revenue. Are there special care techniques I need to learn for such things as changing dressings, helping someone swallow a pill, giving injections, using special equipment? Why is this medicine prescribed? Additionally, patients are released from hospitals “quicker and sicker” than in the past, making it even more critical to arrange for good care after release. • … %PDF-1.5 %���� Does the pharmacy provide special services such as home delivery, online refills, or medication review and counseling? This checklist is designed to outline recommendations known to help in maintaining or establishing postpartum recovery. or herbal preparations that my relative is taking now? To help, a private geriatric care manager (for whom you will pay an hourly fee) or a social worker can offer much needed advice and support. • Talk to your doctor and the staff (like a discharge planner, social worker, or nurse) about the items on this checklist. You may have other obligations such as a job or childcare that impact the time you have available. Develop better educational materials, available in multiple languages, to help patients and caregivers navigate care systems and understand the types of assistance that might be available to them, both during and after a hospital stay. If you need to hire paid in-home help, you have some decisions to make. discharge plan with national guidelines, review of appropriate steps in an emergency, transmission of discharge summary to physicians and services, assessment of patient understanding, provision of a written discharge plan and telephone call from the pharmacist. Of the 178 surveys return … Discharge planning and social work practice Soc Work Health Care. Part of that decision may be affected by whether the help will be “medically necessary” i.e., prescribed by the doctor, and therefore paid for by Medicare, Medicaid, or other insurance. Reward hospitals and physicians that improve patient well-being and reduce readmissions to hospitals. This fact sheet was prepared by Family Caregiver Alliance and reviewed by Carol Levine, Director, Families and Health Care Project, United Hospital Fund. There is also a scarcity of research on social work discharge planning outcomes (Preyde, Macaulay, & Dingwall, 2009). What services will help me care for myself? Hiring In-Home HelpCaregivers Guide to Medications and Aging, Next Step in Care Not all hospitals are successful in this. What agencies are available to help me with transportation or meals? 1028 0 obj <> endobj A social worker. If you are a caregiver, you play an essential role in this discharge process: you are the advocate for the patient and for yourself. Are there special facilities/programs for dementia patients? Caregivers, patients, and advocates are continuing their efforts to alter our healthcare system to make discharge planning a priority. prescription and nonprescription? Discharge Planning process and includes a checklist that could be ... Physicians, nurses, discharge planners, social workers, and August If you donʼt agree that your loved one is ready for discharge, you have the right to appeal the decision. Finding those services can take some time and several phone calls. An inmate’s discharge needs will be generally addressed 30–90 days prior to his or her release date. Are there means for families to interact with staff? Social workers function in a variety of work settings, one of which is the nursing home — also called a long term care facility. Even simple measures help immensely. Versus Usual care – no further Your first step is to talk with the physician and discharge planner and express your reservations. The discharge planner should be familiar with these community supports, but if not, your local senior center or a private case manager might be helpful. Residents of such facilities are often elderly, and the social worker’s duties may be related to end of life planning or similar activities, according to the University of Iowa (ref 1). Formal appeals are handled through designated Quality Improvement Organizations (see the Resources section). Saved by NLM_4Caregivers. Studies have shown that numerous, and sometimes dangerous, errors can be made in home care when language is not taken into account at discharge. Fill in, initial, and date next to each task as completed. Improve communication between hospital and community-based services. Some studies have revealed that surprisingly simple steps can help. If that isnʼt enough, you will need to contact Medicare, Medicaid, or your insurance company. Discussions among experts on improving transitional care and discharge planning have centered on improvements that emphasize education and training, preventive care, and including caregivers as members of the healthcare team. Make transitional care a Medicare benefit; change reimbursement policies to cover more home-based care in addition to institutional care. Convenience is a factor—you need to be able to easily get to the facility—but the quality of care is very important, and you may have to sacrifice your convenience for the sake of better care. Traditionally discharge planning has been conceptualized as helping patients make the transition from the hospital to the community. United Hospital Fund Who pays for this service? ABSTRACT Our work explores a brief historical development on discharge planning in hospitals and examines its significance in medical social work by considering the role of the hospital social worker. While you may not be a medical expert, if youʼve been a caregiver for a long time, you certainly know a lot about the patient and about your own abilities to provide care and a safe home setting. Are there any foods or beverages to avoid? Improve training for healthcare staff, including ways to respond to language, culture, and literacy differences. Have I been given information either verbally or in writing that I understand and can refer to? The hospital must let you know the steps to take to get the case reviewed. discharge. (415) 434-3388 | (800) 445-8106 Where do I get these items? ... McCroskey, Professor, School of Social Work, University of Southern California This manual was funded by a grant from The California Endowment. How will our regular doctor learn what happened in the hospital or rehab facility? They will also advocate for appropriate services on behalf of the inmate. How does it work? Will someone come to my home to do an assessment to see if we need home modifications? Where can I find counseling and support groups? * Adapted with permission from www.nextstepincare.org, United Hospital Fund. You may have very little time and little information on which to base your decision. Do we need special instructions because my relative has Alzheimer, Eating (are there diet restrictions, e.g., soft foods only? SNF DISCHARGE CARE PLAN MEETING CHECKLIST. A listing of all facts and tips is available online at https://www.caregiver.org/fact-sheets. This person coordinates the discharge, making sure that everything happens when it should. Find inspiration for your hospital to undertake discharge … Write down a name and phone number of a person to call … Social Work Role in Discharge Planning . The social work intervention which contributes to effective discharge planning is evidenced by a social worker’s ability to manage patients’ continuing care needs at hospitals and in community-based health settings without recurring need for acute or emergent care services. Discharge Planning and Outcomes Measurement A discharge planning checklist can give you a sense of how intensive recovery will be for a client and how much effort will likely be needed to ensure good outcomes. Although both the American Medical Association and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) offer recommendations for discharge planning, there is no universally utilized system in US hospitals. If you or your family member are more comfortable speaking in a language other than English, an interpreter is needed for this discussion on discharge. Is the building safe (smoke detectors, sprinkler system, marked exits)? This Fact Sheet will look at the keys to a successful transition from hospital to home, explain some important elements, offer suggestions for improving the process, and provide caregivers with checklists to help ensure the best care for a loved one. Do I have transportation to get there? Unfortunately, these hiring decisions are often made in a hurry during hospital discharge. %%EOF Social Work & Discharge Planning Social Work & Discharge Planning. Our Social Work & Patient Flow team is here to assist and support you in making plans for your discharge. Family and friends also might assist you with home care. How long the will the medicine have to be taken? As a part of this planning, the SNF must develop a discharge summary to help ensure that the resident’s care is … 101 Montgomery Street | Suite 2150 | San Francisco, CA 94104 | 800.445.8106 toll-free | 415.434.3388 local. How many staff are on duty at any given time? The few studies that evaluate patients with social work involvement in discharge She had a very serious fall in 2013 and after being hospitalized for a few days her neurologist required her to have 24 hour care. Yet, the way this transition is handled—whether the discharge is to home, a rehabilitation (“rehab”) facility, or a nursing home—is critical to the health and well-being of your loved one. It also should include information on whether the patientʼs condition is likely to improve; what activities he or she might need help with; information on medications and diet; what extra equipment might be needed, such as a wheelchair, commode, or oxygen; who will handle meal preparation, transportation and chores; and possibly referral to home care services. You will need to check directly with the hospital, your insurer, or Medicare to find out what might be covered and what you will have to pay for. Have I been trained in transfer skills and preventing falls? If your loved one has memory problems caused by Alzheimerʼs disease, stroke, or another disorder, discharge planning becomes more complicated, and you will need to be a part of all discharge discussions.