Week 2- Case Management, Discharge Planning, and Documentation

Question 1

PART 1: CASE MANAGEMENT

Answer 1

PART 1: CASE MANAGEMENT

Question 2

• Case management is primarily associated with patients with ____-_____ medical conditions. It is utilized by hospitals, insurance companies, and employers.
• It is a collaborative process involved in the _________, _________, _________, _______ _________, and __________ to meet the patients needs.
• It is designed to provide patients with resources to assist in their success and to achieve _____-_________ outcomes.
• The Case Manager is typically a ______ or ___________.

Answer 2

• high-cost
• assessment, planning, facilitation, care coordination, and advocacy
• cost-effective
• nurse or social worker

Question 3

Duties of Case Managers:

• _________ to identify appropriate patients for case management services. (high-cost, long stay)
• ________ and _________ the delivery of care by the healthcare team.
• Making _________ arrangements and following up with patients.
• Evaluating the outcomes of care for each patient.
• Checking _________ available and coordinating with other _________.
• Recommending insurance policy coverage exceptions where appropriate.
• Coordinating referrals to _________ and arranging for other special services.
• Coordinating care with community services.
• Verifying medical reasons for employee absences.
• Education workers with chronic conditions.

Answer 3

• Screening
• Planning and coordinating
• discharge
• benefits, benefits
• specialists

Question 4

What are the (2) main instances where a PT is likely to encounter professional collaboration with a case manager?

Answer 4

1. ) Work-related injuries

2. ) In the hospital

Question 5

For patients with work-related injuries, we are likely to have ________/__-______ check ins with case managers to check progress towards goals/return to work.

Answer 5

weekly/bi-weekly

Question 6

For patients in a hospital setting, we are likely to have ______ collaboration with case managers including discussion of discharge planning decisions.

Answer 6

daily

Question 7

What is the role of PTs with Case Managers?

Answer 7

Communication status and needs of the patient as it relates to your professional evaluation.

-Important to consider specific information Case Managers need to know as it relates to the PT needs of the patient (can the pt tolerate discharge to recommended setting, safe to be discharged home, type of PT services needed upon discharge).

Question 8

PART 2: DISCHARGE PLANNING (CONCLUSION OF THE EPISODE OF CARE)

Answer 8

PART 2: DISCHARGE PLANNING (CONCLUSION OF THE EPISODE OF CARE)

Question 9

When does discharge planning occur?

Answer 9

Day 1

Question 10

What are a few limitations that need to be considered when it comes to discharge planning?

Answer 10

• insurance limitations
• financial limitations
• personal life limitations

Question 11

Discharge Planning:

• Begins on _______
• Documented in __________
• This indicates that planning has been anticipated from the ______ of care.

Answer 11

• Day 1
• POC
• onset

Question 12

What are some things that are anticipated with discharge planning?

Answer 12

• pt transition to next level of care at discharge
• pt needs at discharge regarding DME
• pt needs for referral/inclusion of additional healthcare providers

Question 13

What are the (4) components of effective discharge planning?

Answer 13

1. ) Patient, family, or caregiver education
2. ) Plans for appropriate f/u care or referral to another agency
3. ) Instruction in a HEP
4. ) Evaluation of modification of the home environment to assist the pt returning home

Question 14

At the conclusion of the episode of care, we are focused on __________.

Answer 14

outcomes

Question 15

• __________/___________ of intervention was replaced by the term ____________ of _____________________.
• ___________ Summary was replaced by the term ____________ of _______ Summary.

Answer 15

• Discharge/discontinuation of intervention
• Conclusion of Episode of Care
• Discharge Summary
• Episode of Care Summary

Question 16

The Conclusion of the Episode of Care is intended to indicate what?

Answer 16

“Intended to indicate that a single episode of care has ended when the anticipated goals and expected outcomes have been met.”

Question 17

What are the criteria for Conclusion of Episode of Care?

Answer 17

• achievement of goals/optimal level of function
• lack of progress/no longer requires skilled care (pt decline continues, continuation not feasible, PT determines pt will no longer benefit)

Question 18

What are the (5) components of the Episode of Care Summary?

Answer 18

1. ) Current physical or functional status.
2. ) Criteria/justification for termination of PT services in that setting.
3. ) Degree of goals/outcomes achieved.
4. ) Reasons for goals/outcomes not being achieved.
5. ) Plans related to the patient or client’s continuing care (HEP, referrals, recommendations for follow up PT, family/caregiver training, equipment provided).

Question 19

Current Physical or Functional Status:

• You will have established the patient’s current functional status at the ________ __________.
• In the Episode of Care Summary, you will update the patients _________ ________ _______ to reflect where they are at the completion of the episode of care.

Answer 19

• Initial Evaluation

- current functional status

Question 20

Criteria/Justification for Termination of PT Services:

• Here you relay the results of your reexamination and outline your _______________ of the course of care.
• Also included is a ___________ as to why skilled care is no longer needed.
• If impairments remain, include a __________ as to the plan of how the remaining impairments will be addressed

Answer 20

• clinical impression
• justification
• justification

Question 21

Degree of Goals/Outcomes Achieved:

• Same as indicated in the reexamination.
• Basically providing an update of ______ __________ status.
• Include _____ goals written throughout the course of care.
• Can indicate achievement status with ______ ro simply statement of _________/___________.
• Remember that a __________ for why goals were not achieved must be included.

Answer 21

• goal achievement status
• all (even if the goal was achieved by the first reexamination)
• ratio (50%) or goal met/goal not met
• rationale

Question 22

Reason for Goals/Outcomes Not Being Achieved:

-Important to include ________ for why the goals or projected outcomes were not achieved.

Answer 22

rationale

Question 23

Plans Related to the Patient or Client’s Continuing Care:

-Includes plans related to _________ care, including things such as what?

Answer 23

Continuing Care

• HEP
• Referrals
• Recommendations for follow-up PT
• Family/caregiver training
• Equipment provided