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Altru Patient Discharge Team
Lee Rerick, LSW Case Management Supervisor Samantha Peiler, LSW Discharge Team Cherri Mack, RN Nurse Navigator Jeanene Carroll, RN Utilization Review
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Objectives Know what disciplines comprise the Altru discharge team
Understand the roles and responsibilities of the discharge team members Be more knowledgeable of the resources available to our patients, families and to you as professionals Have a basic understanding of levels of care and its impact on patients, families and the health care system Emphasize the importance of partnering with your discharge team members to provide coordinated, patient centered care
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Discharge Team 2 Outpatient Social Workers
1 Pediatric Therapy Department Social Worker 10 Inpatient Social Workers 5 RN Patient Care Navigators 5 RN Utilization Review Nurses 1RN Emergency Department Case Manager (2 half time positions need to be filled) This includes backfill and flex positions
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Triad Model Assigned by primary nursing units with variations in staffing due to unit needs and workload SW Patient Nurse UR Navigator
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Horizontal Team Work ED Case Manager-dual role as an extension of the UR team and discharge planning Outpatient Social Work-pre-planning prior to hospitalization as well as support and resources to prevent hospitalization, re-admissions and improve success in the home environment
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Team Roles Social Work-assess discharge needs, arrange post hospital resources, community facility placements from both inpatient and outpatient settings Nurse Navigator-assess discharge needs and arrange follow up for medically complex patients, as well as disease specific patient education Utilization Review-Informs team of level of care i.e. inpatient, outpatient, observation, insurance authorizations, physician education
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Patient Focused Discharge Planning
Screening- Current resources and support systems Reason for admission Change in functional status “Must see” Consults LACE tool-high risk 30 day readmissions Five day Review
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Patient/Family Engagement
Care plan development and understanding Patient/Family needs Identifying available support and resources Emotional Support
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Patient/Family Resources
Outpatient Social Worker Home Health Hospice Medical Home Team Community Placement Options Assisted Living Basic Care Nursing Home Swing Bed Acute Rehabilitation Hospital LTACH Other
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Interdisciplinary Communication
IDT-Daily Inter-Disciplinary Team Meeting Physician Rounding
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3 Levels of Care Outpatient-Procedures with a length of stay expected to be less than two midnights Observation-Used for those patient’s who do not meet medical necessity criteria or whose expected length of stay is anticipated to be less than 2 midnights Inpatient-Patients whose length of stay is expected to be at least two midnights and meet the requirement for medical necessity Exception-Inpatient Only list: Total shoulders, Carotid endarterectomies
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Level of Care Process Emergency Department level of care screening
First level review-Inter Qual (UR nurse) All patients are reviewed on admit to determine the appropriate level of care Second level review-Executive Health Resources (physician consulting group) Observation patients are reviewed by the UR nurse twice per day to determine if they meet inpatient criteria Patients do not automatically change to inpatient at the 48 hour point
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Examples of observation Cases
GI bleed not requiring transfusion Seizures Detox with CIWA<15 Chest pain Syncope Asthma Allergic Reaction Constipation Pain-back pain, nonspecific pain, abdominal pain TIA Dehydration Hypoglycemia Weakness Failure to thrive Falls
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Patient Impact for Medicare Observation Patients
Does not qualify patients for Medicare coverage at a skilled nursing facility Medications that are ordinarily self administered are not covered MOON- Medicare Outpatient Observation Notice Signed by patients
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Thank You From The Altru Discharge Team
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Questions ?
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