Discharge Planning

The Process at Hillsdale Community Health Center

Mission Statement

 Hillsdale Community Health Center is an independent, not- for- profit community hospital dedicated to EXCELLENCE.

Vision Statement

 Guided by our mission, each one of us is fully committed to exceed customer expectations by providing comfort and continuing improvement in healthcare in an efficient, courteous manner to all.

Discharge Planning

    Meeting the patient’s continuing healthcare needs after discharge. Necessitate the admission to the hospital or May occur as an expected outcome to medical and/or surgical intervention. Identify a patient’s uniqueness for: physical, physiological, social and spiritual needs.

Discharge Planning

   Begins on the day of admission Physicians and therapists also assess their patients Discharge Planning staff also review patient charts daily for patients with a potential need for assistance.

Agencies/Resources

       Long-term care Short-term care Home Health Hospice Sub-acute care Rehabilitation Support Groups       Durable medical equipment Adult Foster Care Mental Health Community Agencies Wound Care I.V. Therapy

‘ Automatic’ high risk Adult Referral

    Homeless Home Intravenous therapy Suspected Abuse New diagnosis CVA     Hip/Knee replacements Fractures Trauma victims Psychosocial concerns or crisis intervention needs

Pediatric ‘High Risk’ Referrals

   Trauma victims Femur fractures requiring specialized cast application Suspected abuse   Home intravenous therapy Anticipated long-term school absence

    

Referral Screening Criteria: The following are considered in addition to diagnosis

Age 65, lives alone Inadequate or no known social support system  Suspected abuse/neglect/failure to thrive History of readmission within 30-60 days  Chemical/substance abuse Readmission within 15 days  Changes in body image (colostomy, etc)  Terminal condition Transfer from another facility  Attempted suicide

Referral Screening cont:

   Apparent inability of patient/family to follow the treatment plan Inability of patient to return home in view of feelings expressed by family Inability of family to respond to normal guidance in preparing to cope with the patient’s dependency, disability or behavior resulting from the illness or injury.

   

Department Referral

The Discharge Planning department has an open referral policy for all patients. A referral can be made by anyone with concern for the patient.

A referral can be a physician order or initiated by the Discharge Planning department without an order.

The Discharge Planner will meet with the patient/family within one business day of the referral (excluding w/e & holidays).

Documentation of the Discharge Plan will be found in the Progress notes so that all medical team members are aware of the Plan.

Adult Protective Services

  An adult has the “right” to live anyway they choose as long as they are oriented and competent. If the patient is not oriented and determined incompetent, and does not have a POA or guardian, then an APS referral needs to be made.

Who determines competency? A Neurologist, Psychiatrist, or Phd Psychologist

Adult Protective Services

     Other times a referral might be made (if they are not alert/oriented): If patient does have POA or guardian and they have been neglected or abused.

If the patient does not have any POA or guardian and they require medical attention.

If patient has been abandoned (See Attached HCHC Policy)

Child Protective Services

   Most often referral is through the ER Complete documentation on a 3200 Form (See attached) and call Hotline (See attached policy) Original 3200 is mailed to DSS and copy maintained in our office

     

Child Protective Services

Times a referral might be made: Once a child is admitted in the hospital if parents are neglectful, abusive, or physical with the child A NB whose mother/father is neglectful, abusive, or physical A NB whose mother/father has low IQ ability to adequately care for child (documented & confirmed by family/friends) If child confesses any type of apparent neglect/abuse Disagreement of adoption status between mother & father

Skilled Nursing Facility

    Placement occurs after a 3 day hospital stay (so Medicare will cover first 20 days at 100%) Patient needs a ‘skill’ such as: therapy, nursing care (IV therapy, wound care) Medicare does not pay for ‘custodial’ care (Pt needs assistance with ADL’s and has no skill) Two required forms need completed for admission; one signed by physician (mental illness screening)

Home Care Referral

   Patient must be homebound Patient must have a ‘skill’: therapy, nursing care (wounds, IV therapy, diabetic management, etc).

Home Care is a good transition after a SNF stay

Mental Illness & Substance Abuse

 The mentally ill patient has the option of voluntarily seeking treatment programs, either in-patient or as an out-patient. Sometimes this decision is made on an involuntary basis.

 Those who have a history of substance abuse actively chose if they would like to attend treatment facilities/programs. Substance Abuse programs are self referrals by the patient. The patient is given a list of programs by the Discharge Planner.

Questions, Comments……..

Thank you for attending!