Sometimes it appears there is really no end to the processes governing the management of the skilled nursing center. From admissions to marketing to clinical competence to discharge planning – which is our major focus in this Blog. We have long advocated for the nursing home to make meaningful usage of external case managers in the discharge planning process. Why?
Because external, independent case managers (often nurses and social workers) may have a deeper and wider knowledge of available, quality of life oriented resources, including in community based care. Referral sources or placement agencies are typically not driven by clinical acumen or plan of care development. They tend to price match a shopper of care with a care provider. This does not mean they do not care about quality, generally they simply are not driven by clinical professionals.
The discharge process can lag and lag. Families shut down at the prospect of having to make tough decisions affecting the care of someone they love. Guardians can be overwhelmed with tons of cases. As the nursing home wrestles to avoid uncompensated care, do its part to help minimize premature hospital re-admissions and coordinate meaningful discharges that serve the patient well, a reliable and competent partner in the community is a major asset.
Case management societies and groups can step-up, even arranging compensation agreements with community based care providers. As long as these agreements are governed by fair play and favor what is best for the patient and not the highest referral or case management fee, the arrangement can work well.
All of us can benefit from certain institutional partnerships. The nursing home is no different.
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