Discharge Planning Update for Medicare

Remedy Patients

Restorative nursing program established for
patients

Direct communication with center staff
Care conference within 5 days from admission
date

Caregiver training

Discharge date communication
Physical Therapists

Occupational Therapists

Speech Therapists

Physical Therapy and Occupational Therapy
Assistants
Role Playing Exercise

Case Study Analysis of a Medicare Remedy
Rehab Patient
Four Week Course

Three Days a Week

1 hour each day
Ability to plan discharge upon evaluation

Caregiver training completed

Direct communication with center staff

Restorative Nursing Program Established
Ability to identify discharge plan
Ability to identify barriers to discharge
Ability to use home healthcare services and
durable medical equipment companies for safe
discharge to home
Ability to establish a safe discharge transition to
home
Caregiver training for safe discharge transition to
home with center staff, responsible party or
group home representative
Identification of possible barriers to safe
discharge transition to home and a plan to
overcome those barriers
Utilization of Restorative Nursing Program
Conduct caregiver trainings without error

Therapist will have direct communication with
responsible party, patient, center staff or group
home representative for the discharge planning
process
Therapist will train center staff in restorative
nursing program
Direct Communication will occur within 24
hours of completion of evaluation for the
discharge planning process
Encourages critical thinking skills

Collaborative learning

Role Playing

Case Peer Review

Power Point Presentations

Educational Videos on Discharge Planning


Start Date August 20, 2014

Four Weeks

Three Days Per Week

One Hour Sessions

Discharge Planning Worksheet

Medicare Remedy sample forms

Sample patient cases for Peer Review

Role Playing Discharge Planning Activity

Educational Modules

Positive Outcomes

In service on Medicare Recovery Audits

Observations

Questioning

Discussion

Self Assessments
Surveys sent to the therapists that participated in
the training after the completion of the training

Focus Groups

Chart Audits on Discharged Patients

Test prior to training and after the training

Preferred Facility for Rehabilitation Patients

Therapists and center staff awareness of
discharge planning process leads to reduced
occurrences of rehospitalization
Landau, Valerie. (2001). Top 10: Developing a
Project Management Plan Instructors Notes.
Retrieved August 16, 2014 from,
http://www.roundworldmedia.com/cvc/module10
/notes10.html
Evaluation Toolbox. (2010). Summative
Evaluation. Retrieved August 16, 2014 from,
http://www.roundworldmedia.com/cvc/module10
/notes10.html