Discharge Planning & Transitions for Patients With Complex Care Needs

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Video Runtime: 46 Minutes; Learning Assessment Time: 29 Minutes

Home health and hospice clinicians, case managers, and discharge planners face many challenges when transitioning patients with complex care needs to and from home care or hospice. This course defines the steps involved in the development of a discharge plan, identifies potential barriers to an effective implementation, offers strategies for managing those barriers, and reviews measures of success and outcome achievement related to effective discharge planning. In closing, a case study is used to operationalize, highlight, and reinforce the concepts discussed in the course.

Meet your instructor

Georgia Hockenjos

Georgia Hockenjos, BSN, RN, is vice president and COO of Aleckna and Associates, Manalapan, New Jersey. Ms. Hockenjos has more than 40 years' experience in the home care industry, with more than 15 years in a management or director-level position at a large multibranch nonprofit home care agency (VNA) and 20 years as vice…

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Chapters & learning objectives

1. Care Transitions, Discharge Planning, and Complex Care Definitions

This chapter introduces and defines the concepts of discharge planning, transitions of care, and complex care to ensure the terminology is consistent and understood throughout the course.

2. Conditions of Participation: Discharge Planning

This chapter is a thorough review of the Medicare Hospital Conditions of Participation § 482.43, which describes discharge planning. It includes identification of patients in need of discharge planning, the evaluation, components of the plan, and reassessment requirements.

3. The Process of Discharge Planning

This chapter utilizes the care planning process as a framework for developing an effective discharge plan. The steps included in the process are conducting an assessment, developing the plan, implementing the plan, and measuring the success or outcomes.

4. Case Scenario

This chapter is a review of an 85-year-old patient with multiple diagnoses and complex care needs who is being discharged to home. The steps involved in developing, implementing, and measuring the discharge plan to home—and, ultimately, to hospice—are discussed, with the goal being to include all the concepts discussed in the course.

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