SOCW 6204 Walden University Discharge Planning Strategy Discussion

Respond to at least two different colleagues’ postings in one or more of the following ways:

• Share an insight gained from having read your colleague’s posting.
• Provide a constructive critique of your colleague’s post. Share two additional factors that might be involved in the discharge planning process.

DB 1

Logan,

According to Beder (2006), in 1986 a federal legislation was created in order to ensure that every hospital have a process for discharge planning for a patient. Discharge planning is done to ensure the safety and quality of care of patients after they discharge from the hospital to ensure they do not end up back in the hospital after discharge. It also helps manage a patient’s hospital stay from an insurance benefit, to ensure the patients are receiving the best care with little cost to the patient’s insurance company, while keeping the length of stay short as well.

The roles of a medical social worker are too; complete assessments, create a plan, implement the plan, coordinate services and interventions, monitor to ensure the services and interventions are working, and then to evaluate to see if they can continue the plan or if an adjustment to the plan should be made. According to Beder (2006), an essential component to discharge planning, is finding after care services such as home health, medical equipment, transportation, or medications the patient will need after discharge.

Discharge planning incorporates all of the practice skills in the generalist intervention because, it helps to promote the well-being of the patient while continuing to follow the NASW ethical guideline and considerations. I am currently a discharge planner/medical social worker, and I feel that I complete a lot of patient advocacy. I have to advocate for my patient to have a certain service or to be included in a certain program, in a timely manner in order to ensure they have the correct resources needed prior to discharge from the hospital. Beder (2006), provides a detailed account of being a discharge planner with individuals who have had a stroke, he mentions thatmany of these individuals often stay in a hospital/ rehab setting for up to three weeks, which is very accurate, while the goal is to always return home, sometimes that is not possible due to the level of care a patient may need once they return home, so they end up discharging to another facility for continued therapy prior to returning home.

A challenge that I face, when working with other professionals involved in discharge planning, is that they have a limited view or knowledge of what a discharge planner is and our role in the process. They often times do not understand utilization review process, and how sending in medical updates to a patients insurance company can lead to a denial in services, and I have to advocate on behalf of the patient to their insurance company why they need certain services or to stay in the hospital a little longer. It seems odd that I am still providing other professionals that I work with basic education on what a discharge planner is, and how it is not always my role to interact with a family and or patient to discuss a diagnoses or medications and how a nurse or doctor is more competent in those subject areas. I feel that there is still a lot of education that could be completed at my place of employment that could result in better communication about what a case manager/discharge planner does and does not do.

Reference:

Beder, J. (2006). General medical social work. In Hospital social work: The interface of medicine and caring (pp. 9-20). Routledge. https://doi.org/10.4324/9780203956120

DB 2

Ebony,

Proper discharge requires planning and evaluation of treatment needs, the Discharge Planning Strategy is a great model to reference when working with clients that need to transition from the hospital to where they go to get additional care. That can be home or an inpatient facility. The plans acronym IDEAL stands for:

Include the patient and family as full partners in the discharge planning process.

Discuss with the patient and family five key areas to prevent problems at home.

Educate the patient and family in plain language about the patient’s condition, the discharge process, and next steps at every opportunity throughout the hospital stay.

Access how well doctors and nurses explain the diagnosis, condition, and next steps in the patients care to the patient and family and use teach back.

Listen to and honor patient and family’s goal’s, preferences, observations, and concerns.

Strategy 4, Ideal Discharge Planning (Implementation Handbook)

Key factors in discharge planning include; medication protocols, what care will look like at home, information on where and when follow up appointments need to be conducted, and information about who to contact if and there are questions or if there are any issues after discharge.The medical social worker should serve as the liaison between hospital staff , outside care providers and the patient. According to Beder, the central goal of discharge planning is for the social worker to fully address the high;y individualized needs of each patient and provide safeguards at home for his or her care (2006).

During the discharge plan the social worker should identify barriers, that includes transportation to appointments, explanation of insurance benefits and how they play a part in the cost of medication and outside care needs. Beder also adds that, the social must also have a network of and knowledge of community- based services and an understanding of how these services can best be accessed in the service of the patient upon discharge ( 2006).

The generalist intervention model is a key component in discharge planning. application of the generalist intervention model can help a wide range of systems in any setting or size. The seven stages in the generalist intervention model serve as a road map for social workers and facilitates client involvement throughout the problem solving process, protecting their right to self determination and ensuring that goals, tasks and changes reflect their clients preferences and capabilities.

Medical social workers may face a number of challenges; this includes burn out, having empathy for patients and not working in cohesion with other disciplines. Burn out can be the result of working long hours, having large case loads and lack of self care. Working with other disciplines can create challenges in work ethic, bed side manner and lack ofknowledge aboutcommunity programs. Social workers are known to be very empathetic, this can take an emotional toll on us.

Reference:

Agency for Healthcare Research and Quality. (n.d.). Care transitions from hospital to home: IDEAL discharge planning implementation handbook. Retrieved from https://www.ahrq.gov/sites/default/files/wysiwyg/p…

Beder, J. (2006). General medical social work. In Hospital social work: The interface of medicine and caring (pp. 9-20). Routledge. https://doi.org/10.4324/9780203956120