1. CASE MANAGEMENT DISCHARGE PLANNING Stephanie Ford

2. Objectives * Recognize the benefits that case managers provide for patients. * Identify tasks that case managers/discharge planners are responsible for. * Be able to identify patient needs upon discharge. * Identify ethical concerns regarding discharge planning.

3. Nurse Case Managers  Different locations  Collaborate  Create standardized plans of care  Coordinate  Advocate  Utilize Resources  Monitor and Evaluate  Quality and cost effective care  Continuation of care  http://www.youtube.com/watch?v=RXgiNrvDxws http://www.youtube.com/watch?v=RXgiNrvDxws

4. Discharge Planning  Evaluation  Discussion  Planning  Determining  Referrals  Arranging  IDEAL http://www.youtube.com/watch?v=Un7As1R2-HU

5. Interview  Kim Ford- Director of Patient Support Services at Sparrow Hospital  The future of discharge planning  Challenges

6. Theories  Imogene King- Theory of Goal Attainment -personal, interpersonal, social  Weick’s Health Communication Theory - enactment, selection, retention

7. Environment  When to begin discharge planning?  Who is involved?  Joint Commission  Quality care/safety

8. Case Study  Joanna is a 40-year-old female who was diagnosed with multiple sclerosis(MS) 7 years ago after experiencing numbness in her legs and an MRI revealed characteristic brain lesions of demyelinating disease. She was prescribed an interferon (IFN)-beta formulation. Over the last 5 years, MS has affected every aspect of her life. Last year she began to experience increasing physical disability and difficulty driving. As a single mother of 2, she worries constantly that she may no longer be able to work and support her kids. She has not been faithfully adhering to her prescribed IFN regimen because she struggles with the injections. Recently, she experienced a worsening of symptoms including double vision and spasticity in her legs. After several days of experiencing these symptoms, Joanna awoke one morning to find that she could not move her arms or legs normally. She immediately called for an ambulance and was admitted to the hospital.

9. Root Cause Analysis

10. Implications  Patient outcomes  Smooth transition  Obtaining Resources  Education/Knowledge  Comfort  Satisfaction http://www.youtube.com/watch?v=WmJS1edls8 w

11. QSEN  Patient- Centered Care  Teamwork and Collaboration  Safety

12. ANA Standards  Standard 8- Education  Standard 13- Collaboration  Standard 15- Resource Utilization  Standard 16- Environmental Health

13. Discharge Planning Game  http://www.virginiageriatrics.org/residents/dp/dis chargeplanning/index.htm http://www.virginiageriatrics.org/residents/dp/dis chargeplanning/index.htm

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