Discharge Planning
Discharge planning nurses work with recipients and hospital staff to review aftercare plans, with a focus on recipient health goals, home care action plans, monitoring schedules, and assistance with other activities and/or services including:
- Scheduled follow up visits with both primary and specialty care providers
- Medication adherence
- Recipient-driven symptom management
- Home health care
- Durable Medical Equipment (DME)
- Rehabilitation therapy
- Care management
- Coordination of benefits from any other payers
- Indications of any potential quality of care or utilization issues
Discharge planning nurses also identify patients with high risk conditions for whom the transition to outpatient treatment may result in worsening health outcomes and readmissions. Discharge planning nurses conduct biopsychocosial assessments to identify and take action to minimize risk and prevent readmission.