Module A: Philosophy and Standards

CE Credits: 2.0

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This module lays out the importance (and potential pitfalls) related to a patient’s discharge plan from the hospital—especially when that patient will need follow-up or ongoing outpatient care. First, the module details the core elements of the discharge process—in particular, how CMs must navigate questions about insurance coverage—and defines the essentials of a patient-centered plan, from coordinating language-appropriate services to setting achievable goals. The module then covers the ways that the CM should include the transdisciplinary team, especially in terms of ongoing communication about the patient’s goals and needs. Finally, the module reviews the standards of practice of the American Case Management Association (ACMA) and The National Association of Social Workers (NASW).

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Learning objectives: After completing this module the case manager will be able to:
» Identify the core elements of discharge planning
» Discuss transitions of care and care coordination in discharge planning
» Describe the economic effects of discharge planning
» Advocate for transdisciplinary team efforts
» Review CM credentials, licensure, certification and practice standards

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Advance your professional practice:: Case managers are vital liaisons between patients and the rather daunting (and often fragmented) healthcare system. By understanding the ways that a poorly executed discharge plan can harm patients, case managers can work for smoother transitions out of the hospital and for much better outcomes for patients.

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Improve organizational performance: Hospitals seek the best outcomes for their patients, while also seeking to get as much reimbursement as possible for their services. Understanding a thoughtful and well-executed discharge plan helps team members do both for patients and healthcare organizations.