RespiteMatch.com Health Blog

POLICY ELEMENTS

Clear policies and protocols for managing and directing the practice of discharge planning
High risk identification process that functions as a problem solving forum and resource coordination manager supported by the highest level of administration that engages all the players (e.g. Case Management, Social Worker, Administration, Legal, Risk Management, ethics, business, Chaplain, financial, external agencies)
Early planning and intervention to identify/discuss safety issues in order to make the necessary linkages with community services
Ability of the home care agency to implement accessible flexible staffing
Electronic HIPAA compliant uniform record sharing among stakeholders with standardized policies and protocols to guide the exchange of information
Shared knowledge base that informs discharge planners concerning safety issues and solutions
Established standards for discharge planning throughout a continuum of care at home based on: education; accountability; individual choice and peer support
Consolidated/accessible/current database of resource information designed to educate and inform professionals about available resources
Standards to establish uniform practices for the exchange of discharge information
Establish relationships with local resources including adult/child protective service agencies
Discharge and service plans that are realistic and attainable in a reasonable time frame with available resources
The availability of a 24/7 care management safety net
Recognition/acknowledgement of individual’s rights and informs persons of their rights applied to the discharge planning process and educates persons about service options, financial options, etc.
PROCESS ELEMENTS

A person centered assessment process that is proactive and careful in assessing problems/concerns
A person centered assessment process that focuses on the person’s strengths vs. deficits to ensure consumer directed care and control
Communication and coordination among formal and informal caregivers and stakeholders that is designed to mobilize resources and identify potential solutions
Engagement and support from the multi-interdisciplinary team including physicians
Collaboration with community advocates concerning safety issues and solutions as needed
Utilization of peer support to prepare persons for transition between levels of care and to help sustain persons in the least restrictive setting