What does a hospital discharge planning team do?
Every hospital has a discharge planning team made up of nurse care managers and social workers. Physical Therapists, Occupational Therapists, Registered Nurses and Pharmacists are brought in as needed. This team is responsible for the documentation that proves you require the care/treatments given by licensed nurses or rehabilitation staff. Medicare calls this a “Skillable Need”. It is during the discharge process, that a determination is made about getting post-hospital help at home or a rehab facility.
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The discharge process begins prior to hospital admission when a social worker assesses discharge needs and your situation. Financial status and insurance coverage is reviewed to ensure that services after discharge are available and to determine what authorizations may be needed. The safety of your home environment and ability of family to care for you at home is uncovered through discussion. The home evaluation includes what items will be needed at post-discharge (e.g. walker, grab bars). Assessing the home environment is critical to this process since the expectation is that you will eventually go back home.
Discharge planning team members:
Nurse Case Manager
The nurse case managers oversee patients’ care plan during the hospital stay and serves as a liaison between the patient, family, and healthcare professionals.
The social worker best understands insurance requirements, services available in the community and eligibility requirements. The social worker meets with the patient and family to apply for programs that will help like transportation and handicap placards.
The physical therapist evaluates functional abilities, which determines post-hospital care. Functional abilities are evaluated using specific criteria as set out by insurance. These criteria are directly connected to the level of care patients require after their stay in the hospital.
Physical therapists evaluate:
The occupational therapist evaluates a patient’s ability to function independently based on Activities of Daily Living (ADLs) and safety within their own environment. The focus is on recovery of physical skills and skills needed to continue previous activities (e.g. cooking, driving).
Occupational therapists evaluate:
What happens at discharge:
Per regulations, the discharge team must ask the patient for three options on where they would like to go upon release. The hospital cannot make recommendations or influence your choice.
Unfortunately, once the physician(s) have determined you can be released from the hospital, the turnaround time between this decision and your release can be as little as an hour. The discharge team has little time to explain options for decisions you need to consider. Frankly, once you are cleared for release they need you out of the hospital bed as soon as possible. This puts you in a real bind. What is the likelihood that you will know of three local post-acute care facilities if that is what is being recommended?
- Prior to discharge, the rehab facility will call your insurance company for you, but being proactive yourself is best.
Disclaimer: The material in this blog is for educational purposes only. It is not intended to replace, nor does it replace, consulting with a physician, lawyer, accountant, financial planner or other qualified professional.
With thanks to my collaborator on the Rehabilitation series, Emily Lintag
Emily Lintag is a hospital and health care professional who has served as a sub-acute rehabilitaion nurse, assisted living charge nurse and wellness nurse. In addition to serving as coordinator and hospital liaison with several rehabilitation facilities.