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Category Archives: Discharge Planning

UPDATE: Centers for Medicare and Medicaid Services (CMS) Revisions Christy Rakoczy

June 3rd, 2013 | 0

CMSOn May 17, 2013 the Centers for Medicare and Medicaid Services (CMS), a division of the Department of Health and Human Services, issued a Memorandum in regards to the revision of the State Operations Manual. The revision applies to the State Operations Hospital Appendix A, Interpretive Guidelines for Hospitals, Condition of Participation: Discharge Planning, in order to “update the guidance for the discharge planning Condition of Participation.”

The revisions to Appendix A include interpretive guidelines that are italicized and written in red to denote the portion of the appendix that has been updated.

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Ellen Belluomini, Our Featured Health Care Trailblazer Ninette Tan

May 29th, 2013 | 1

ellen outside 008Over the past few weeks I have gotten to know a great contributor to the world of social work and health technology by the name of Ellen Belluomini. She along with many others has inspired me to create a new monthly OpenPlacement blog special edition called “Featured Healthcare Trailblazers.”

Ellen has created an insightful blog for social workers and health professionals who are beginning to advocate for technological advances called Bridging the Digital Divide in Social Work Practice. As health professionals we are all working towards the same goal to innovate and improve the quality of care. Read on to find out where Ellen’s passion stems from.

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Listen Up, What Doctors Aren’t Communicating Effectively to Seniors Christy Rakoczy

May 23rd, 2013 | 5

DrCommunicationIn a time when hospital readmissions rates are being closely analyzed and hospitals are attempting reforms to improve those rates, it is crucial to take a look at patient populations most frequently readmitted to hospitals and the reasons for readmission. Among those populations of people most frequently readmitted to hospitals, seniors are in great number. Poor discharge policies can be to blame.

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The Art of the Follow Up Call Christy Rakoczy

May 20th, 2013 | 2

SeniorOnPhoneFollowing up with patients after giving care is a crucial means of developing a strong patient relationship. It is also the key to improving overall patient care and reducing patient readmissions in the hospital setting.

Follow up calls can address a variety of issues. One common type of follow up call is to report lab results. Another type of common follow up call is to schedule appointments. However, calls can also be made to ensure patients have made appointments with referrals or are taking medication appropriately. Other calls may have the purpose of education or reinforcing knowledge. There are myriad factors that could warrant a follow up call to a patient. 

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Top Eight Characteristics of A Successful Social Worker Christy Rakoczy

May 13th, 2013 | 9

HelpingHand Social work is a fulfilling, yet demanding, profession. In order to be successful as a social worker, there are traits that are necessary to possess and build.

Characteristic 1: Highly knowledgeable and well-trained
In order to be a successful social worker, one must possess the knowledge and the skills to effectively do the job. In order to acquire content knowledge, a degree from an institution of higher education is necessary. Most social work positions require at least a Bachelor’s degree, but a Masters degree, Ph.D, or other certification work is highly helpful to prepare for this career.

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Post-Hospital Syndrome: The Silent Enemy Christy Rakoczy

May 2nd, 2013 | 2

PostHospitalSyndromeWith the advent of new penalties for hospitals in an effort to reduce readmissions, it is critical to explore post-hospital syndrome, its causes and prevention.

Post-Hospital syndrome is the condition of a patient after being treated in a hospital. About 20 percent of Medicare patients who receive treatment for an initial condition such as heart failure, COPD or pneumonia are readmitted within 30 days for other acquired conditions. The secondary conditions may include mental illness, heart failure, pneumonia, or gastrointestinal disturbance, to name a few. 

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Which Care Transition Model is Best? Christy Rakoczy

April 22nd, 2013 | 2

Which Care Transition Model is Best?Care transition models play a huge role in lowering readmissions. Patients, families, and medical providers depend on these models to answer the “What, When, and Who” during a deterioration in a condition after being discharged. Hospitals have developed these models to point out to patients and their caregivers what red flags to look out for in their medical condition, when to make that call, and who to contact to attain appropriate care. Due to a fragmented healthcare system, the models have provided solutions in unifying medical providers into one system so patients receive timely and non-repetitive aftercare. I have looked into five current care transition models and outlined their differences to help you determine which is best. 

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Clinician Resources to Promote Improved Hospital Discharge Processes Christy Rakoczy

March 7th, 2013 | 0

CareTransitionIn our fast-paced and ever changing world, medical personnel face the challenge of providing quality and personal care to a vast number of patients.  With the number of people being treated in hospitals increasing, it is very important for the discharge process to be as smooth and informative as possible.  Breakdowns in communication between facilities and caregivers during hospital discharge processes can cause serious and sometimes life-threatening situations, and in recent years several resources have been created to prevent such situations from occurring. 

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Understanding and Improving Discharge: A Critical Factor in Reducing Potential For Readmission Christy Rakoczy

January 28th, 2013 | 0

Discharge_1Introduction.  Recent studies have shown that the discharge process can be very difficult.  The challenges of the complex process can easily lead to errors that lead to unnecessary re-hospitalization.  Preventing these both improves the patient’s outlook and prevents care facilities from receiving penalties associated with excessive readmissions.  This report takes a look at the discharge process and some of the data gathered over the last several years as a means of understanding and improving discharge.

The importance of effective discharge planning.  Studies from the Agency for Healthcare Research and Quality demonstrated that there were more than 39 million discharges in the United States in 1996.  Unplanned re-hospitalizations cost a whopping 17 and a half billion dollars, accounting for nearly a fifth of Medicare’s hospital payments between 2003 and 2004.  The end result, according to the Centers for Medicare and Medicaid Services’ Readmissions Reduction Program, is that in 2012, about two out of every three facilities received some sort of penalty for excessive readmissions.

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Tips When Working With Seniors With Behavioral Problems Christy Rakoczy

January 10th, 2013 | 0

BehavioralProblemsWorking with behavioral problems among elderly patients can be exhausting.  Inexperienced caregivers sometimes respond poorly to such behavior, which can, in some cases, lead to verbal or even physical abuse.  Placement of these individuals is another matter all together – because they are so difficult to deal with, it is extremely difficult for discharge planners and social workers to find facilities that are able and willing to provide them the special care that they need.  Here are some practical tips we’ve found make the process of working with seniors with behavioral problems a bit easier.

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