Assisting patients with care and arrangements for post hospitalization services is central to both social workers and home health care agencies.
In most hospitals, the federal Omnibus Budget Reconciliation Act mandates that there be a process for planning patient discharges. “According to the Omnibus Budget Reconciliation Act, a discharge plan must be included in the patient’s medical record and discussed with the patient or patient representative.” The law helps facilitate speedy discharge of patients, and the discharge planner plays a key role in a patient's post hospital recovery.
Hospital social workers’ role in planning patients for discharge is indispensable. A social worker helps ensure that patients are able to return home and adapt to their former environment. They support doctors, surgeons and other practitioners treating patients who are recovering from a medical procedure, or managing acute health conditions such as COPD or Parkinson’s, or a disability like spinal cord injury.
In 1984 the American Hospital Association defined discharge planning as an interdisciplinary process guided by the following essential elements:
- Early identification of patients likely to need complex post hospital care
- Indication of patient preferences for post hospital care
- Patient and family education
- Patient and family assessment and counseling
- Planning, development, and coordination of community resources needed to ensure continuity of care after discharge
- Post discharge follow-up to ensure services and plan outcome
BrightStar Care of Cumming and Gainesville helps assist social workers in coordinating patient care at home from medication management and wound care, to skilled nursing and RN infusion services.
To learn more about how BrightStar Care works with discharge planners and social workers to support a patient’s hospital discharge and help create a recovery care plan, visit our website.
Source: https://www.caregiver.org/hospital-discharge-planning-guide-families-and-caregivers