Discharge Planning
RSSArticles
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A Guide to Training Nurses on Transitional Care
It is challenging to find a tailor-made educational and training program for registered nurses to learn transitional care. A VA hospital created its own program, called the Transitions Nurse Training Program.
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Care Coordination Training Works Well for VA Hospitals
One of the challenges facing health systems as patients are moved from the hospital to another healthcare facility is how to make these transitions as safe as possible — especially in rural and underserved areas. A Veterans Affairs hospital has found a possible solution through its Transitions Nurse Training Program.
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Communication in Care Transition Process Needs Improvement
The care transition process is challenging, especially for patients with multiple complex conditions. To provide the best care to high-risk patients, case managers, community providers, and clinicians need to optimize communication. Case managers can improve the process through quality improvement efforts that focus on overcoming dialogue challenges and identifying providers’ communication preferences.
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How Case Managers Can Help Patients Reduce Heat Risk
Extreme heat events can become cluster death events. Case managers and health systems can help their patients — especially older patients with heart and/or lung disease — to prevent heat illness.
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Climate Change Could Be Newest Social Determinant of Health
Extreme heat events cause tens of thousands of hospitalizations and ED visits each year. Heat is particularly dangerous for older adults and patients with heart and lung illnesses. Case managers and hospitals can help prevent heat exhaustion by educating at-risk clients about how to stay cool and recognize symptoms.
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The Importance of the Physician Advisor
The physician advisor role has been evolving over the last couple of decades. Case managers are discovering their relationships with these clinicians can be incredibly valuable when made a priority.
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Embarking on Case Management Research
As case managers go about their days, they are constantly discovering and solving problems, often without even realizing it. Part of the role is to troubleshoot issues with discharge, utilization management, and more — but once the issue is resolved, that often is the end of it. However, when case managers seek solutions for their problems, they are engaging in research.
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Reservation Program Saves Beds, Prevents Readmissions
A health system tackled the challenges of transitioning patients to SNFs through a relationship with a multisite SNF. Together, the organizations created a bed reservation program, which results in a smoother and more effective transition process.
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Discharge Navigators Facilitate More Efficient Transitions
SNF beds were limited in one hospital’s region, even before the COVID-19 pandemic decimated nursing home staffing across the United States. ECU Health’s solution has been to assign a discharge navigator to work on obtaining authorizations for transferring patients to SNFs. Instead of waiting for the SNF to obtain authorization for a particular patient, the discharge navigator handles this task.
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Standardized Process for SNF Transitions Helps Prevent Readmissions
Using Lean methodology, Monument Health in Rapid City, SD, created a care transition process that reduces excess hospital days, prevents readmissions, and shortens the time it takes from discharge order to the patient leaving the hospital.