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Monday, August 26, 2013
  Clinical Accuracy Spoken Here  

DC Planning: Communicating Care Transitions

When moving the patient to another facility, customer satisfaction is improved when patients have a contact from acute-care that is in direct communication with someone at the post-acute facility.

Ideally, all the pertinent information about the patient is communicated and questions are answered. However, studies indicate that even the patient's paperwork does not always accompany the patient being transitioned to another facility.

Leaders from the American Medical Directors Association (AMDA) have shown that skilled nursing facilities do not receive a discharge summary from the hospital approximately 28 percent of the time.

[Reference: Discharge Planning, Module B, Patient Centered DP]
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  Excellence in Case Mgmt  

DC Planning: By the Numbers

America spent $2.6 Trillion on health care services in 2010. This translates to $8,402 per person or 17.9% of the nation's Gross Domestic Product (GDP).

Among hospitalized patients 65 or older, 23 percent are discharged to another institution, and nearly 12 percent receive home health care.

Among patients discharged from a SNF, 19 percent are readmitted within 30 days.

On average, patients 65 or older with two or more chronic conditions see seven different physicians within one year, accounting for 95 percent of Medicare expenditures.

[Reference: DC Planning, Module B, Pt. Centered DC Planning]
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  Improving Patient Care...  

DC Planning: Standards Provide Direction

The American Case Management Association (ACMA) has developed standards of practice to describe the responsibilities of the CM and establish CM accountability.

Standards are a necessary element for collaborative relationships to work efficiently and effectively and provide a:

  • Direction for case management practice
  • Framework to evaluate this practice
The CM and the other members of the interdisciplinary care team are jointly accountable for measurable outcomes that are cost effective and reflect patient preferences and values.

[Reference: DC Planning, Module A, Philosophy and Standards]
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Tom RasmussenTom Rasmussen
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