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System Based Practice

"Homeward Bound"medicaid

A Module about Discharge Planning
Patricia Beach, MD, Sally Robinson, MD, Shirley Anderson, LMSW

This is a Systems-based Practice module from the UTMB pediatric team caring for children with special health care needs (CSHCN).

This module is designed to help you develop the skills needed to be a Primary Care Provider for a special needs child. You will decide how to plan for discharge for a child who lives in town located miles away from a children's hospital and CSHCN team. You will then consider some of the challenges of being a Primary Care Physician for that child, a role that can be very time consuming unless you are familiar with the support services available for you to do your job with a minimal amount of effort.


  1. List the steps necessary to implement the discharge of a medically complex patient from the hospital.

  2. Determine sources of financial support for the medical needs of medically complex children.

  3. Determine how to identify and obtain the equipment needed by children with complex medical conditions.

  4. Identify which personnel should be responsible for securing equipment and referring to other local facilities.

  5. List the qualifications and responsibilities of a Primary Care Physician for medically complex children.

  6. List the responsibilities of medical specialists for medically complex children.

  7. Determine transportation needs and support for medically complex children.


last updated July 2016