Transitional planning has become more than just the movement of the patient out of the hospital. It is a “process” that starts at the point of admission and follows through to the community and the post-acute care providers. The Center for Medicare and Medicaid Services has specific requirements for this process. This program will review those requirements. It will also discuss the challenges hospitals are facing as they assume more risk some of the new payment models, such as bundled payments. Strategies for safely transitioning your patients across the continuum of care will be discussed. In addition, we will review how to engage other members of the interdisciplinary care team in the process of planning for the patient’s movement across the continuum including verbal and written hand-off communication. Transitional planning is no longer a destination but a process! Learn how to align with the next level of care providers and ensure that your processes address the complexities of the new healthcare environment.
Planning for the transition, both in the hospital and out of the hospital has progressed over the past several years. Case management professionals, both RN case managers, and social workers now must understand the required processes, as well as understand how transition delays may put the hospital at risk for loss of revenue and patients at risk for negative events. This session will integrate the previous session webinars to assimilate the discharge planning process with other case management roles and functions. New case managers and social workers must have this information to understand the strategies presented which can help ensure they are contributing to optimal department outcomes.
- Understand the role of transitions in care for case managers today
- Describe why managing transitions have become vital
- Review the CMS requirements related to transitions
- Discuss how to interface with all members of the interdisciplinary care team during transitions
- Learn how to align with post-acute providers and why that is so important
- Review the types of transition delays you may experience and what you can do about them
- Identify those high-risk patients who may benefit from enhanced transitions management
Areas Covered in the Session
- Foundation of effective transitional planning
- Current rules, regulations, and standards for transitional planning
- Preparing for a CMS survey with the Conditions of Participation for discharge planning
- Barriers to effective discharge planning
- Case Management department strategies for effective discharge planning
- Physician collaboration with discharge and transitional planning
- Multidisciplinary rounds
- Readmission impact of ineffective discharge planning
- Sample dashboard metrics
- Director of Case Management
- RN Case Managers
- Director of Finance
- Director of Social Work
- Social Workers
- Physician Advisors
- Director of Nursing
- Chief Medical Officers
- Post-acute care providers
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About the Presenter:
Toni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing, and evaluating acute care and community case management models, provides education on case management and related topics, and on-site assistance to case management departments.
The author of nine books and a frequently sought-after speaker, lecturer, and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management.
Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management journal in which she shares insights and information on current issues and trends in case management.
Prior to her current work as a case management consultant, Dr. Cesta was Senior Vice President – Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York. Prior to her position as Senior Vice President at Lutheran Medical Center, Dr. Cesta has held positions as Corporate Vice President for Patient Flow Optimization at the North Shore – Long Island Jewish Health System and Director of Case Management, Saint Vincents Catholic Medical Centers of New York, in New York City and also designed and implemented a Master’s of Nursing in Case Management Program and Post-Master’s Certificate Program in Case Management at Pace University in Pleasantville, New York. Dr. Cesta completed seven years as a Commissioner for the Commission for Case Manager Certification.
You will receive an email with login information and handouts (presentation slides) that you can print and share with all participants at your location.
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