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In these times of fixed payments and increased financial risk, healthcare organizations cannot afford to keep patients at one level of care for an extended period of time, especially one that is of high acuity, intensity or cost. Ongoing assessments for timely transfers to the appropriate level of care are necessary to protect organizations from the risk of denial for reimbursement of services rendered. Transitional planning provides a structure that ensures the interdisciplinary healthcare team provides patients with appropriate services in the most appropriate level of care as delineated in the standards and guidelines of federal and private regulatory and accreditation agencies.
This series will focus on case management as it transitions patients across the entire healthcare continuum: communication strategies and handoffs, engagement with the patient and family, payment methodologies, the role of the case manager in the acute care and community-based settings, and strategies for integrating patient care across the continuum. Transitional planning is an important case management tool for managing care, outcomes and cost across the continuum.
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|- Mapping processes||- Effective handoffs||- Outcomes|
|- Discharge dispositions||- Key social work roles||- Documentation|
|- Care transition strategies||- External transition strategies||- Episodes|
|- Bundled payment history||- Future bundled payment proposals||- BPCI|
|- Key case manager roles||- Mandatory bundled payment models||And more!|
|- Roles in community||- Differences in roles||- Similarities in roles|
|- Roles in acute care||- Outcomes across continuum||- Project BOOST|
|- Identifying high risk||- Psychosocial patients/families||- Risk stratification|
|- Processes across continuum||- Coleman Care Transitions Model||- Project RED|
|- Aligning resources & needs||- Naylor Transitional Care Model||And more!|
|- Hospital-isolated silos||- Communication & coordination||- Standards of practice|
|- Statement of philosophy||- Multiple healthcare providers||- Written vs. verbal|
|- Time out as an effective tool||- Professional roles & responsibilities||- Rounding|
|- Post-acute care isolated silos||- Effect on Medicare spending||- Effective CM teams|
|- Guiding team principles||- Facilitation, coordination and collaboration||And more!|
|- Crucial conversations||- Provider rounds||- Daily goals|
|- TJC safety standard #2||- Clinical documentation||- Walking rounds|
|- Pharmacist rounds||- Walking rounds check list||- Scripting|
|- Key structural points||- Engaging patients & families||- Talking points|
|- Staff nurse rounds||- Vertical vs. horizontal communication||And more!|
|- Transitional CM role||- Identifying high-risk patients||- Input|
|- Patient influences||- Transitional outcome measures||- Output|
|- Transition time outs||- Accountable care organizations||- Time outs|
|- Community-based care||- National Transitions of Care Coalition||- Throughput|
|- Best practice transitions||- Discharge planning as transitional planning||And more!|