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A discharge planner is a master's degree-prepared social worker (MSW) or registered nurse (RN) responsible for coordinating a patient's discharge from an acute-care hospital or medical center to his home or to a longer-term facility, such as a nursing home or rehabilitation center. Although they are called discharge planners, their responsibilities begin with a patient's admission and continue throughout the patient's inpatient stay. A discharge planner usually works within a hospital's utilization review office, the department responsible for documenting the necessity of a patient's continued inpatient care to the appropriate insurance companies. In the US, discharge planning has been required of all hospitals that participate in the Medicare program — essentially, all American hospitals — since the applicable law was passed in 1986. Adequate discharge planning is particularly important as cost-control measures that abbreviate inpatient stays in Western hospitals mean that many patients are discharged while still requiring assistance with personal or medical care.
As indicated, a discharge planner begins to work upon a patient's admission by making note of the patient's age, diagnosis, condition, type of insurance or lack thereof, usual degree of independence, living arrangements and social support system. All of this information helps determine the general direction of the patient's developing discharge plan. Despite the early establishment of the plan, a great deal of preparatory work can be completed by a discharge planner in anticipation of the patient's eventual hospital release. For instance, an elderly, widowed patient who will undergo the surgical repair of a hip fracture will need to be discharged to an extended care facility, or nursing home, for additional recovery and physical therapy rehabilitation. If this same patient were to be discharged after treatment for pneumonia, however, her discharge destination would probably be her home with home health care, home oxygen therapy and any durable medical equipment indicated by her needs.
When a discharge planner determines that a patient can return home safely, she then assesses what services the patient might require and what the patient's insurance will provide. Home health care might be indicated in some form or combination of nursing visits, certified nursing assistant visits, physical therapy instruction or respiratory therapy if home oxygen is necessary. Any necessary durable medical equipment (DME) such as hospital beds, hospital bed tables, wheelchairs, bedside commodes or walkers will be rented and delivered in anticipation of the patient's arrival home. If necessary, transportation by ambulance, wheelchair ambulance, or cab is arranged. The discharge planner might even arrange for Meals On Wheels® or any other available public nutrition program for which the patient might qualify.
Finally, the discharge planner will arrange a return appointment for the patient to see her doctor or doctors. A list of discharge medications with drug information brochures will also be provided. The patient will also receive instructions to follow up on after her return home, as well as a contact name and number should additional questions arise.
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