Maximizing Patient Decision and Choice Through an Innovative Acute Care Transition Model

Abstract

In 2014, ProHealth Care assessed and reorganized the care management department. Areas of focus included management of the transition of care from inpatient to the community setting. Condition of Participation: Discharge Planning CFR 482.43 1 Centers for Medicare & Medicaid Services Conditions for Coverage (CfCs) & Conditions of Participations (CoPs). https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/index.htmlDate: November 6, 2013 Google Scholar and the new Centers for Medicare & Medicaid Services (CMS) IMPACT Act 2 Centers for Medicare & Medicaid Services IMPACT Act of 2014 & Cross Setting Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014-and-Cross-Setting-Measures.htmlDate: October 28, 2015 Google Scholar require that we offer choice based on the skilled need of the individual and level of quality of care delivered at the facility to which the patient will be transitioned. Through thorough evaluation of our discharge planning process, we learned that patients/families did not feel qualified to make quick decisions in selecting community facilities/agencies to transition at discharge from the hospital. We also learned that our staff was compartmentalizing the steps into increments that were neither efficient nor helpful to patients and families. For example, a staff member would select 3 facilities from an approved list based on geography; present them to the patient and family; wait for a prioritized selection from the family; contact the facilities enumerated; and wait for facility acceptance; and then, if denied, start the process all over again. This broken system wasted everyone's time and energy, and created a frustrated patient and family, whose hearts were set on a particular provider.