2019 - Improving Hospital Case Management Care Transitions: Discharge Planning Through Transition to Community

Transitional planning as a process
CMS’s transitional care management services
Case management transitions
Role of RN case manager and social work case manager in discharge planning
The admission assessment role in the discharge plan
Triggers for social work consults in complex discharge planning
Supportive case management roles for discharge planning: perioperative case manage, complex discharge planning case manager, case management assistant
Influences on transitional planning
Discharge planning compliance
Proposed changes for Conditions of Participation: discharge planning from CMS
Communicating across the continuum of care
The interdisciplinary impact on transitional planning
The outcomes dashboard for discharge planning