Q&A: Having the right tools for discharge planning

Q: What does a case manager need to know when helping a patient with their discharge plan?

A: No matter where in the hospital a patient is located, the case manager must be ready to assist the patient and his or her family and develop an appropriate discharge plan. Discharge planning starts whenever the case manager applies his or her skills in collaboration with the care team, the patient, and his or her family to determine what the right care is for this patient, where the best setting is to receive the care, and when he or she should move to that care setting.

Discharge planning must take into account the patient’s status, since some benefits, like Medicare SNF benefits, can only be accessed if one is admitted as an inpatient for at least three consecutive days. Yet in the current healthcare environment, the case manager may be called upon to assist with discharge planning issues in various settings.

Knowing what qualifies for observation or inpatient status by understanding a patient’s condition and plan of care will help the case manager advocate for a change in status for patients in extended recovery or outpatient in a bed status. If the stay is not qualified for observation or inpatient care, the case manager must have a broad knowledge of the needs of the patient and what services insurances will pay for, as well as what options are available when there is no payer source for the preferred discharge plan, so that the patient will be safe after discharge.

Communication is crucial to determine what assistance the patient already has within his or her family and social system and which resources will need to be supplemented.

For more information, see Case Management Patient Communication Toolkit. Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.