"Homeward Bound"
(Discharge Planning)


Systems Based Practice
 


Practice Guidelines

EMTALA

Discharge Planning

HIPAA

Professional Organizations
 


Pediatrics


Now compare your responses to the suggestions below:
 
Function PCP, CRCT or Both Comments
Evaluate patient when he gets sick Both Ideally the PCP is the medical home and provides primary care services to Brian.  However, there is often a period of transition for complex or unstable patients. Brian’s mother may prefer to bring him back to the CRCT for even minor problems until she gains confidence in her new doctor.  Dr. Stark may be uncomfortable with some of Brian’s problems and prefer this arrangement as well.  In some cases a qualified PCP is never located for the child and the CRCT continues to  provide a mix of primary and specialty services.  Since Brian is enrolled in a Medicaid Managed Care Program, the CRCT must have referral authorization to see Brian, though no referral is necessary for him to be evaluated in the Emergency Dept., and hospital admission, if indicated, does not require authorization by his PCP.
Provide well-child care and immunizations PCP Brian should follow standard recommendations for well child care and immunizations.  This can be an important step in facilitating development of comfort for both parent and PCP in receiving services from the PCP.
Assess developmental progress   PCP/CRCT   The PCP will assess development as a part of routine well-child care.  Detailed assessment will probably occur during routine CRCT visits.  Developmental progress will be followed by the local infant stimulation program as well.  
Determine equipment needs   CRCT   A PCP may determine needs for some equipment.  PCP authorization may be needed on forms for equipment such as a wheel chair.  Measurements for a wheelchair would likely occur at the time of a CRCT visit.  The CRCT social worker would then complete the forms for durable medical equipment and fax to the PCP for signature.  
Authorize disposable supplies PCP If Brian needs more disposable supplies, such as suction catheters, his mother will notify the vendor, who will complete forms and fax to the PCP for signature.  
Review and sign orders for Home Health Assistance   PCP/CRCT   Once it is determined that in-home services are needed,  the orders and the chart notes are faxed to the home health agency preferred by the family, and arrangements are made for services to begin.  The inpatient social worker does this.  Modifications to the plan or additional orders are signed by the ordering physician.  For example, if Brian needs to have albuterol nebs q 2-4 hours for several days when he develops a URI, the home health nurse may call Dr. Stark for a verbal order which will be faxed or mailed for signature. Or Dr. Stark may supply written orders at the time of an office visit.  Changes in care developed at the time of a CRCT visit will be signed by CRCT physicians.  A HHN may even accompany Brain to either facility for office visits.  
Refer to specialists PCP Even if the specialists have been providing services in the hospital, (such as CRCT or ENT) a referral for outpatient services is necessary.  Office personnel will call Dr. Stark for referral if referral authorization has expired, but Dr. Stark should attempt to fax the appropriate referral paperwork prior to visits.  
Hospitalize   CRCT/PCP If at all possible, hospitalizations should be at a pediatric hospital, at least while Brian is very young. Local facilities vary in their ability to deal with unstable small children, and determination of location for hospitalization must be individualized.
Determine when trache and feeding catheter can be removed   CRCT in consultation with ENT or Surgery PCP must authorize specialist services  


Continue