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Discharge Planning -

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Person Centered Discharge Planning
Lee Moriarty, BS/CTRSQuality Therapy and Consultation &Illinois Pioneer Coalition Founding Board Member
Objectives of session:
To understand the requirement that discharge planning has in regards to the Federal RegulationsTo share and discuss innovative ideas to help create a person-centered discharge planning process paying particular attention to helping the individual answer the question what will everyday life look like post discharge.To develop a viable discharge planning process that utilizes the knowledge and resources of the various team members.To use the discharge process to decrease Hospital re-admission by placing more emphasis on who the person is so that quality of life and quality of care needs can be addressed post sub-acute nursing home discharge.
Why we need to talk about this?
About 40 % of Medicare beneficiaries discharged from an acute care hospital go on to use post-acute care (PAC) from skilled nursing facilities (SNFs), home health agencies (HHAs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs).In April 2012 CMS revised the MDS section Q regarding elders expressed desires for dischargeIn November 2016 CMS revised regs to expand what it means to have person centered care planning
Why do we need to talk about this?
People are coming into “nursing Homes”/Rehab centers for post acute care with the desire to go homeWhat is life going to look like when they get home?Roughly 73% of hospital readmissions were deemed avoidable in a recent study by Vanderbilt University researchersWe need to explore what isreallyhappening here?
What prompted the Medicare recipient’s hospitalization to begin with?
Declining healthInjury due to an accident/fallImproper medication managementLack of supports to stay healthy
What is life going to look like post post-acute care?
We do a good job of looking at quality of caresetting up medical care services – home health services, setting up durable medical equipment, etc.We don’t do a good job of looking at quality of lifeHow will you spend the day?
Impact of asking about quality of Life –What will life look like when you go home?
CMS has been asking this question too!
And they want us to look at in a more person centered manner!Definition added in November 2016 –CMS definition for person-centered careto focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives (Definitions 483.5).
OBRA Regulations: F204(Rev. 168, Issued: 03-08-17, Effective: 03-08-17, Implementation: 03-08-17)
§483.15 (c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.This orientation must be provided in a form and manner that the resident can understand.
OBRA Regulations: F284(Rev. 168, Issued: 03-08-17, Effective: 03-08-17, Implementation: 03-08-17)
§483.21(c)(1) Discharge Planning ProcessThe facility must develop and implement an effective discharge planning process that focuses on the resident’s discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading topreventable readmissions.
OBRA Regulations: F284
Discharge SummaryWhen the facilityanticipatesdischarge a resident must have a discharge summary that includes,but is not limited to, the following:Now it says:§483.21 (c) (2)(iv)A post-discharge plan of care that is developed with the participation of the resident and,with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment.The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services.
Additional Changes under Comprehensive Care Plans §483.21(b) :
The facility must developand implementa comprehensiveperson-centeredcare plan for each resident…(B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Assessing Resident's Desire for Discharge:MDS 3.0 Section Q Interviews
MDS 3.0 Section QApril 1, 2012
Section Q has broadened the scope of the traditional boundary of discharge planning for sub-acute residents to encompass long stay residents. In addition to home health and other medical services, discharge planning may include expanded resources such as assistance with locating housing, transportation, employment if desired, andsocial engagement opportunities.(RAI Manual Chapt. 3 page Q-10
From for Healthcare Improvement)
“When a patient’s transition from the hospital to home is less than optimal, the repercussions can be far-reaching — hospital readmission, an adverse medical event, and even mortality. Without sufficient information and an understanding of their diagnoses, medication, and self-care needs, patients cannot fully participate in their care during and after hospital stays. Additionally, poorly designed discharge processes create unnecessary stress for medical staff causing failed communications, rework, and frustrations. A comprehensive and reliable discharge plan, along with post-discharge support, can reduce readmission rates, improve health outcomes, and ensure quality transitions.”
Effective discharge planning
Leads to :decreased chance that the patient is readmitted to the hospitalhelps in the overall recovery processensures medications are prescribed and given correctly in the transitionAdequately prepares the patient/family to transition into the next phase of carePromotes improved quality of life post dischargeImproves resident’s confidence upon discharge
How to Set-up a Person-Centered Discharge Plan:
Start discharge process at admissionAsk:Patient: what is the patient’s discharge plan/goal?Family: what is the family’s discharge goal- does this goal match the pt’s goal?Assemble team to discusswiththe patient goals and how to implement these goals
Discharge concerns
Lets talk about the Plagues…
Loneliness, helplessness and boredomCould this influence discharge success?Do you address the potential for these through discharge planning?
Solution to the plagues -
Ask: How do you plan on spending the day once you go home?Assess reality of the plan along with the pt.Process through adaptations and need to be proactive to take control of how this day will look.
Quality of life ideas to transition home more successfully:
NetflixPea PodMeals on wheels/home meal deliverySenior transportationChurch assistancePark district programsSenior clubsOther??
The key to a successful discharge:
Communication!Hold a care plan so all team members have the ability to effectively discuss discharge options with the elder and their familyRemember we need to develop the Person Centered Care plan within 7 daysUse the MDS schedule of 5, 14, 30, 60 ,90 days
Discharge planning starts on day of admission!
Discharge instructions should include at a minimum:
The individual’s preferences and needs for care and supportspersonal identification and contact information, including Advance Directives;provider contact informationbrief medical history;current medications, treatments, therapies, and allergies;arrangements for durable medical equipment;arrangements for housing;arrangements for transportation to follow-up appointments;contact information at the nursing home if a problem arises during discharge
Discharge instructions should include at a minimum:Continued
A follow-up appointment with the designated primary care provider in the community and other specialistsMedication education.Prevention and disease management education, focusing especially on warning symptoms for when to call the doctor.Who to call in case of an emergency or if symptoms of decline occur.ANDHow will your day look when you get home? How do you plan on spending your day?
Sample Discharge Forms
Assessment draftCMS Discharge Planning Booklet
Confidence = Success
When an individual feels in control of their body both physically and cognitively, they will have better success upon discharge from supportive rehab to home
Thank you for your time!Contact information:Lee [email protected]





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Discharge Planning -