![]() ![]() ![]() Discharge plan is developed in collaboration with healthcare team & family & meets patient needs & financial requirements. ![]() Appropriate resources are identified to provide discharge services & promote a safe transition to the next most appropriate level of care. Appropriate use of health care services & allocation of resources is encouraged to improve quality of care & maintain a balance with cost effective care on a case-by-case basis. Patient & family are empowered to problem solve to achieve desired outcomes & promote patient self-determination. Patient centered team meetings are planned & conducted to coordinate healthcare team members & third-party payers to achieve treatment outcomes & discharge planning goals Education is provided to the interdisciplinary team, the patient & the family about treatment options, community resources, insurance benefits & psychosocial concerns to ensure timely & informed decisions. Case management plan is developed collaboratively with the interdisciplinary team, patient & family to maximize health care responses, quality & cost-effective outcomes, incorporating patient & family goals, expectations, & preferences into the development of the interdisciplinary plan of care Communication & coordination is actively promoted between members of the interdisciplinary team, the payer & the community to minimize fragmentation of services & to maximize outcomes. Assessment of the patient?s health & psychosocial needs is conducted per established guidelines. Collaborate with the interdisciplinary team, patient & family, as well as various departments within & outside the hospital to assure timely & appropriate discharge planning & cost-effective outcomes. Oversee the assessment, planning, facilitation, coordination, evaluation & advocacy for options & services to meet a patient & family?s comprehensive health needs & to promote quality cost effective outcomes. Facilitate the coordination of care, from admission through discharge, with focus on realistic treatment outcomes within the scope of available resources. ![]()
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