NHDP

Technical Assistance

Activity 1

Study Design

Study Topic: Discharge Planning

Read the following study topic:

Skilled Nursing Facility (SNF) discharge planning is a service to assist patients in arranging the care needed following a skilled nursing facility admission. Skilled nursing facility social workers and/or case manager’s help arrange services including home care, nursing home care, durable medical equipment out-patient medical treatment and other help. The basics of discharge planning include planning, training and referral. Proper discharge planning dictates that the following events occur:

Prior to discharge from the SNF the facility case manager or social worker should:

  • Perform an assessment to determine appropriate setting for discharge
  • Evaluate if Medicare home care services are appropriate
  • Arrange for appropriate home care and durable medical equipment such as wheelchairs, walkers, bedside commodes, hospital beds, tube feeding equipment, and respiratory equipment delivery to the clients residence
  • Organize or arrange for transportation home for the client
  • Schedule or instruct member to arrange a follow up appointment with the clients primary care physician or specialist as appropriate
  • Provide the client with written discharge instructions including a medication list with specific instructions on medication dosages and how long they should be taken
  • Ensure the client has prescriptions for medications or that client already has appropriate medications at home

Weekly staffing meetings for those Long Term Care Community Diversion Pilot Project members currently admitted to a SNF demonstrate that these members are at risk for inadequate skilled nursing facility discharge. Skilled nursing facility discharge planners lack knowledge regarding the Long Term Care Community Diversion Pilot Project, the role of the Plan X case manager, and the implications of inadequate discharge planning in general. In addition, some skilled nursing facilities lack dedicated discharge planning staff and those that do have the dedicated staff may carry heavy caseloads that negatively impact their ability to perform adequate discharge planning.

Potential complications of inadequate discharge planning from a skilled nursing facility include:

  • Placement in a long term care setting when needs could be met in a least restrictive setting
  • Risk of Plan X providing services that should have been provided by another payor source such as Medicare, VA, community or private grants, private long-term care policies, etc.
  • Lack of care coordination between members primary care physician, specialists, skilled nursing facility physician and other providers involved in members care during the admission
  • Delay or disconnect with member following up with primary care physicians and/or specialists involved in care while member was in the skilled nursing facility
  • Medication non compliance and medication complications due to inadequate information regarding medications at discharge as well as lack of providing prescriptions at time of discharge or ensuring client has medications at home
  • Environment and safety hazards if appropriate durable medical equipment is not arranged and delivered timely

Affected Population or Data Base:

1. Long-term care members enrolled in the Plan X Long Term Care Community Diversion Program that have been admitted to a skilled nursing facility during the measurement period.

Study purpose and goal: Case manager to ensure the members admitted to a skilled nursing facility receive adequate discharge planning services.

Desired outcomes include:

  1. Plan X Case managers coordinate with skilled nursing facility staff to ensure that members are discharged from skilled nursing facilities with prescriptions for medications as appropriate
  2. Plan Xcase managers coordinate with skilled nursing facility staff to ensure members are evaluated for of Medicare Home Health services on or before discharge from skilled nursing facility
  3. Plan Xcase managers notify member’s primary care physician of member’s inpatient admission to skilled nursing facility

In conclusion, discharge planning for long term care members admitted to a skilled nursing facility is a priority because this:

Long Term Care Community Diversion members are at high risk forinadequate discharge planning

Write a study question.

Write at least one study indicator.

Identify the eligible population.

Activity 2

Study Implementation

Identify causes/barriers.

Identify interventions.