Question 1) ROle, I am a discharge planner, case manager and utizilation review coordinator at a large hospital
My role is to coordinate or buzz word, Transition to the next level of care for patients going home- do they require home care, have durable medical equiptment needs like a commode or a walker or oxygen, I am responsible to set those services up after I assess the need, speak with the medical team and ask social work to intervene if appropriate. I am responsible for giving the patient resources that may asassist them at home, like aging services, supPort groups, - communication between the medical team, the family and the next level of care providers is vital
2)Since in my role I have responsibilty in utilization review - older clinically experienced nurses do well here, varied backgrounds in many different specialties
for the discharge planner, case manger role, my background in high tech trach and vent home care was very beneficial, another requirement, you can not be shy, you will call a lot of companies and only half know what you are talking about and then need to ask a ton of questions so you kinda get it by the end of your conversations- I had no competencies, and just learned on the job, however you must have a good set of community resources to fall back on
3) While the patient is inpatient the role is to communicate barriers to discharge to the family, patient, medical team ie: patient is 80 and lives alone and does not have available family to assist with IV antibiotic infusions, this would be a problem, so when MD says they are ready for discharge tomorrow.... Not so fast I tell them, we have kinks that need to be worked out first
as they transition to another level of care
home - by setting up home care the hope is to decrease readmission rates by empowering patients to take control of their health with the assistance of the home care team or referring anf identifying the patient to case mangement ( private insurers Aetna,managed medicaids)through the UR process when you call - if a patient lacks the resources at home to care for themselves, be it lack of money for getting scripts filled or no heat- if you can assist with these resources prior to discharge or give the patient the tools to follow up when home- improved outcomes
4) IN the discharge planning mode not really, I do no direct patient care, but with the utilization review piece, where you call all the insurance companies and let them know why the patient is in the hospital and what you are doing every day and how they are progressing towards discharge, we use a set of giudelines that determines the severity of the illness and the intensity of services rendered to see if they could be more cost effectively served at a different level of care ie: acute rehab or skilled nursing facility
