The Case Manager
Discharge Planning is one of the most important functions that workers’ compensation case managers perform.
Depending on where you meet your patient, an inpatient hospital or rehabilitation facility, an outpatient rehabilitation facility, a skilled care facility, or in the home, learning about the discharge plan is critical so you know the plan and the resources needed.
Talking to the patient and the facility case manager, social worker, or discharge planner early about the discharge plan is important, as it gives you a sense of what the injured worker will need in terms of resources and education.
Having the injured worker and their family involved in the plan is important for their buy-in and participation.
Here are some questions you can ask to make sure the discharge plan is meeting the needs of your patient:
- What is the condition of the patient? Are they able to do their activities of daily living themselves, or do they need help? If they need help, who will provide it?
- Can they walk, transfer from the bed, the chair, the toilet, and back to their bed alone, or do they need assistance? Can a family member be trained to do this? Can they take a shower? What equipment is needed for the patient to be safe in the shower?
- Is their home equipped to allow them to move through the home safely?
- Is there a way for them to get out of the house safely if there is a fire or other emergency?
- Does the home need modifications?
- Is the patient able to be alone in the home if the caregivers have to go to work? If not, it is not a safe discharge, and the patient should not be moved till a plan is developed to meet these needs
- Will the patient need therapies or services at home, or can they go to outpatient therapy? If they go to outpatient therapy or doctors’ offices, do they have transportation? These will need to be set up with providers prior to discharge.
- What education does the patient need before they go home? Do they understand what is wrong with them? Do they know their diagnosis? Do they understand and agree with the plan of care? What questions do they have surrounding the diagnosis?
- What medications will they need to take once they go home? Has a medication reconciliation been done with the medications they were on to the medications they are going home on?
- What equipment do they need at home? Have they/the family been taught how to use it? Do they understand the importance of using the equipment?
- Who will follow the patient once discharged? What are the red flags the injured worker/family should be aware?
- When does the patient need to see his primary care doctor, specialists, or go for tests or treatments? Who will set each up?
- The discharge plan is not a one-time event. Once the injured worker is discharged, they will have ongoing needs that must be planned and addressed to support the patient/family. Who will the person be to follow up, monitor, and adjust the plan of care? In Workers’ Comp, hopefully, a nurse case manager is assigned who will be the point person to keep all of the players in the loop
A lot of responsibility is placed on injured workers and their families during the discharge process. It is our role to help them, so they are prepared and safe for discharge.
Each of these questions is designed to help you, the injured worker and his/her family, and the healthcare team determine what is needed for discharge.
The number one question that needs to be answered: Is the discharge safe? This question must be answered before the patient leaves the setting. If they are not safe, then we need to look at Plan B.
I hope this article helps you plan each discharge to meet the individual needs of each patient you work with. Doing so will ensure safe discharges, prevent readmissions and injuries, and involve your patient and their families in the team.
What did I miss? Let me know, and I can include it in part two when I talk about the issues case managers, the injured worker, and the family should be aware of as part of the discharge process, as well as the transition of care
Have a good week!
