Assess the patient's current health and functional status
3
Identify post-discharge needs
4
Approval: Medical Staff for discharge status
5
Develop discharge plan
6
Coordinate with patient's family or support system
7
Coordinate with external service providers
8
Create a list of required medications and instructions
9
Arrange for transportation if necessary
10
Approval: Patient’s Personal Physician
11
Ensure all necessary equipment is ordered and delivery is scheduled
12
Review discharge plan with patient and family
13
Obtain signature from patient or family for discharge
14
Share discharge plan with primary care doctor or specialist
15
Arrange for follow-up care or appointments
16
Approval: Case Manager Supervisor
17
File completed discharge plan in patient’s record
18
Inform the patient's nurses and other caregivers about discharge
19
Perform final medical check-up before discharge
20
Ensure patient leaves the facility safely
Review the patient's medical record
In this task, the case manager will review the patient's medical record to gain a comprehensive understanding of their medical history, diagnoses, and treatments. This information will help in assessing the patient's current health and functional status and identifying their post-discharge needs. The desired result is to gather all relevant medical information and gain insights that will inform the development of the discharge plan. Some potential challenges include accessing a complete and up-to-date medical record, deciphering medical jargon, and identifying missing or conflicting information. To overcome these challenges, the case manager may need to consult with healthcare professionals or request additional documentation. Required resources: Access to the patient's medical record system or physical file.
1
Medication
2
Physical therapy
3
Surgery
4
Dietary restrictions
5
Other
1
Yes
2
No
Assess the patient's current health and functional status
In this task, the case manager will assess the patient's current health and functional status to determine their post-discharge needs and the level of care required. This assessment will include evaluating the patient's physical, cognitive, and emotional well-being. The desired result is to have a comprehensive understanding of the patient's current health and functional status. This information will inform the development of the discharge plan and help in identifying the necessary support services. Some potential challenges include limited patient cooperation, difficulty in gathering accurate information, and interpreting assessment results. To overcome these challenges, the case manager may need to involve other healthcare professionals or use standardized assessment tools. Required resources: Assessment tools, healthcare professionals for consultation.
1
Vital signs
2
Mobility and range of motion
3
Pain level
4
Skin condition
5
Other
1
Memory
2
Orientation
3
Attention and concentration
4
Judgment and problem-solving
5
Other
1
Depression
2
Anxiety
3
Irritability
4
Other
Identify post-discharge needs
In this task, the case manager will identify the patient's post-discharge needs based on their current health and functional status, as well as any preferences or limitations expressed by the patient and their family. This includes assessing the need for home health care, medical equipment, medication management, and community resources. The desired result is to have a clear understanding of the specific support services and resources the patient will require after their discharge. This information will inform the development of the discharge plan and ensure a smooth transition from the healthcare facility to the patient's home or another care setting. Some potential challenges include limited availability of certain support services or resources, financial constraints, and conflicting preferences or limitations. To overcome these challenges, the case manager may need to explore alternative options, seek financial assistance, or collaborate with other healthcare professionals or community organizations. Required resources: Knowledge of available support services and resources, financial assistance options.
1
Nursing
2
Physical therapy
3
Occupational therapy
4
Speech therapy
5
Other
1
Wheelchair
2
Hospital bed
3
Oxygen concentrator
4
Catheter
5
Other
1
Medication schedule
2
Reminder system
3
Prescription refill process
4
Other
1
Transportation services
2
Meal delivery
3
Support groups
4
Home modifications
5
Other
Approval: Medical Staff for discharge status
Will be submitted for approval:
Review the patient's medical record
Will be submitted
Assess the patient's current health and functional status
Will be submitted
Develop discharge plan
Coordinate with patient's family or support system
Coordinate with external service providers
Create a list of required medications and instructions
Arrange for transportation if necessary
Approval: Patient’s Personal Physician
Will be submitted for approval:
Develop discharge plan
Will be submitted
Create a list of required medications and instructions
Will be submitted
Ensure all necessary equipment is ordered and delivery is scheduled
Review discharge plan with patient and family
Obtain signature from patient or family for discharge
Share discharge plan with primary care doctor or specialist
Arrange for follow-up care or appointments
Approval: Case Manager Supervisor
Will be submitted for approval:
Arrange for follow-up care or appointments
Will be submitted
Review discharge plan with patient and family
Will be submitted
File completed discharge plan in patient’s record
Inform the patient's nurses and other caregivers about discharge
