CASE MANAGEMENT

DISCHARGE PLANNING

Stephanie Ford

Objectives

* Recognize the benefits that case managers provide for patients.

* Identify tasks that case managers/discharge planners are responsible for.

* Be able to identify patient needs upon discharge.

* Identify ethical concerns regarding discharge planning.

Nurse Case Managers

Different locations Collaborate Create standardized plans of care Coordinate Advocate Utilize Resources Monitor and Evaluate Quality and cost effective

care Continuation of care http://www.youtube.com/watch?v=RXgiNrvDxws

Discharge Planning

Evaluation Discussion Planning Determining Referrals Arranging IDEAL

http://www.youtube.com/watch?v=Un7As1R2-HU

Interview

Kim Ford- Director of Patient Support Services at Sparrow Hospital

The future of discharge planning

Challenges

Theories

Imogene King- Theory of Goal Attainment

-personal, interpersonal, social Weick’s Health Communication Theory

- enactment, selection, retention

Environment

When to begin discharge planning?

Who is involved?

Joint Commission

Quality care/safety

Case Study

Joanna is a 40-year-old female who was diagnosed with multiple sclerosis(MS) 7 years ago after experiencing numbness in her legs and an MRI revealed characteristic brain lesions of demyelinating disease. She was prescribed an interferon (IFN)-beta formulation. Over the last 5 years, MS has affected every aspect of her life. Last year she began to experience increasing physical disability and difficulty driving. As a single mother of 2, she worries constantly that she may no longer be able to work and support her kids. She has not been faithfully adhering to her prescribed IFN regimen because she struggles with the injections. Recently, she experienced a worsening of symptoms including double vision and spasticity in her legs. After several days of experiencing these symptoms, Joanna awoke one morning to find that she could not move her arms or legs normally. She immediately called for an ambulance and was admitted to the hospital.

Root Cause Analysis

Implications

Patient outcomes Smooth transition Obtaining Resources Education/Knowledge Comfort Satisfactionhttp://www.youtube.com/watch?v=WmJS1edls8w

QSEN

Patient- Centered Care

Teamwork and Collaboration

Safety

ANA Standards

Standard 8- Education

Standard 13- Collaboration

Standard 15- Resource Utilization

Standard 16- Environmental Health

Discharge Planning Game

http://www.virginiageriatrics.org/residents/dp/dischargeplanning/index.htm

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