RespiteMatch.com Health Blog

Transitional Care Planning is a patientcentered,
interdisciplinary process
that begins with an initial assessment of the patient’s potential needs at the time
of admission and continues throughout the patient’s stay. Ongoing consultation
with the patient care team and reassessment of the patient’s changing medical
functional, social and cognitive capabilities assures that the comprehensive
needs of the patient are addressed. Patients and families are apprised of the
appropriate community resources available and encouraged to participate in all
phases of the transitional care planning process. Referral mechanisms with
community providers occur in a timely, systematic fashion in order for the patient
to gain access to identified resources. The process concludes with the
coordination and implementation of services and transition to the least restrictive
level of care in keeping with the individual’s wishes.
· Transitional Care Planning considers the patient’s medical, physical,
cognitive, economic and emotional strengths and abilities as well as their
available support system
· Assessment of the patient’s level of functioning prior to admission
provides insight into resources available post discharge
· Ongoing collaboration between the patient, family and the interdisciplinary
team provides an invaluable link, which facilitates the process of informed
decision making
· Patients and families will receive verbal and written information of the
range of services and available options available in the patient’s
community
· Patients and families will be given the opportunity to select the providers
of services whenever possible
INITIAL DISCHARGE SCREEN
These questions should allow the discharge planner to determine whether the
patient is likely to need a more comprehensive assessment
· Was the patient independent prior to admission?
· Will this current episode of illness impact the patients independence
· Short term or long term?
· Does the patient have adequate informal supports to manage any loss of
independence?
· Does the patient have adequate resources to provide for post discharge
(Hospital, Nursing Home, Certified Home Health Agency) needs, such as
meds, equipment, rehab, or follow up treatment? (Insurance, Private
funds, Medicare, Medicaid).
· If the patient had prior home care services, were they adequate? Are they
likely to be adequate after discharge?
· Are there any special requirements to access?
· Is there a different level of care needed and is there a different payor
because of hospital stay?
· Has this patient had multiple hospital admissions?
HIGH RISK SCREENING CRITERIA
Patients who fall into any of these categories should be targeted for a
comprehensive assessment
· Over the age of 70
· Multiple diagnosis and comorbidities
· Impaired Mobility
· Impaired self care skills
· Poor cognitive status
· Catastrophic injury or illness
· Homelessness
· Poor social supports
· Chronic illness
· Anticipated long term health care needs (e.g.,new diabetic)
· Substance abuse
· History of multiple hospital admissions
· History of multiple emergent care use
COMPREHENSIVE ASSESSMENT
Patients who are identified as High Risk or those for whom a more
comprehensive assessment is indicated should be evaluated using the following
criteria
The screening process is dynamic and may include other information not listed
below.
· Functional assessment (the patients ability to perform ADL’s and IADL’s)
· Cognitive assessment if indicated
· Who are the patient’s informal supports?
· What are the abilities of the informal supports?
· What is the availability of the informal supports?
· What is the patient’s living arrangement? (home, apartment, with family,
congregate living, homeless)
This should include a description of the setting, such as stairs to enter,
wheelchair accessibility, functional plumbing, heat, cooking facilities.
· What is the patient’s understanding of their illness?
· Is the patient capable of participating in his or her own discharge planning,
if not, do they have someone who can represent them in the process?
· What are the patient’s goals for discharge?
· What does the patient need to achieve functionally to achieve these
goals?
· What services might be available to the patient to achieve these goals?
· What services did the patient have prior to admission?
· Does the patient have a preference for service provider?
· Does the patients insurance have a preferred provider network?
· Does this patient have insurance or funds to pay for necessary care, if not
what resources are available to them?
· Is the patient understanding of risks/benefits associated with their
choices?
· Is there a history of noncompliance,
which impacts the ability to be
managed at home?
* This document refers to patient rather than individual/consumer because it
is intended to be used by Hospitals for their patients
Screening and Assessment Flow Chart
Ideally the discharge planning
process should be initiated in the
medical provider office, particularly
for patients who have a planned
admission or an elective procedure.
Basic discharge: no needs outside of
scripts, routine followup
and written
discharge instructions.
Moderate discharge plan indicated: these
patients may need a home health agency
referral, simple DME, community resource
information and or referral. Outpatient
rehabilitation, outpatient followup.
It is
anticipated the patient will have only short
term medical needs. Generally speaking, the
have adequate independence and or social
supports to be discharged home with
minimal intervention.
Community service providers should be
prepared to collaborate with the
discharge planner whenever one of their
patients/clients are admitted to another
level of service, information exchange is
crucial to a successful outcome.
Initial screening can be done by chart
review, patient interview, interdisciplinary
team meeting, available demographic
information, patient diagnosis and history
and other methods, the purpose of this
screening is to identify patients who will
need discharge planning outside of the
routine discharge.
*See high risk screening criteria
Complex discharge planning indicated: these
patients may need inpatient rehabilitation,
Hospice, Dialysis, medically complex home care,
high cost drugs, caregiver respite, LTHHC
program, Consumer directed program, adult
home or nursing home placement, substance
abuse rehab or phsychiatric admission. Included
in this group are the uninsured
or underinsured
with specific discharge needs that require more
funding or those who will have long term chronic
medical needs.
I. Patient Admission
Initial
Discharge
Planning
Comprehensive
Assessment: See
Attached For
Screening Criteria