"Homeward Bound"
(Discharge Planning)


Systems Based Practice
 


 Practice Guidelines

 EMTALA

 Discharge Planning

 HIPAA

 Professional Organizations
 


 Pediatrics


How can the hospital care team best determine if Brian can be discharged to his home?

  1. The physician should interview Brian and his extended family about the home situation to determine if Brian can go home.
     

  2. The hospital social worker should make a trip to the patient’s home.
     

  3. (Correct) A case manager can coordinate information obtained from a physicians, social worker, therapist, or even a home health agency to evaluate the adequacy of the home environment. 
     

  4. The team should contact the vendor of durable medical equipment to assess the home situation.

A very important feature of care for Brian should be his case manager or social worker.  The physicians does not have to make difficult determinations alone. Medicaid, CHIP and many managed care organizations provide reimbursement for “case management services."  A case manager is usually a nurse or social worker with training in how to conduct a home assessment.


Fortunately not all of a child’s care has to be provided by his nuclear family. Prior to discharge all team members are in a position to observe the family’s ability and readiness to provide care at home.; If the team is not comfortable with the resources at home a discharge can be delayed.  In extreme cases, Children's Protective Services might become involved, and ultimately foster care or placement in a relative's care might be required. If home health skilled nursing care is needed it can range from several hours per week to 24-hour per day, depending upon the patient’s needs.


Prior to discharge a case manager or hospital social worker will coordinate the services a child receives to avoid unnecessary duplication. A case manager (or hospital social worker) may be very important in identifying local resources (physicians, therapists, equipment) for Brian. In Brian’s case his case manager may be someone who is already on the staff of the hospital, or it may be someone associated with his Medicaid or other program. One drawback of having case management supported by managed care organizations is that after discharge from the hospital, a child may have a case manager assigned to him by several sources, and coordination of services may suffer.

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