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Working with a case manager I have learned about concerns specific to discharging patients from the acute care setting. Per my preceptor, a problem the organization is facing is creating safe discharge plans for homeless patients. Often patients require additional services at discharge including outpatient wound care or follow up appointments. This makes creating a safe discharge plan difficult as patients that are homeless typically do not have access to necessary resources. Without access to necessary outpatient resources, this patient population is at an increased risk for readmission to the hospital. According to my preceptor, due to this issue, one patient has been readmitted to the hospital 5 times over the last few months.
Readmission is an issue for both the organization and nursing staff. Working with a patient with a difficult discharge plan and high risk for readmission is a challenge for the case managers. There are only so many resources available within the community and once those have been exhausted it can be difficult to create a new, safe, plan. This is also a concern for the organization as depending on the diagnosis, readmission can impact reimbursement rates for the patient’s stay. Being a case managemer requires extensive knowledge of resources and collaboration to create a safe discharge plan for patients. Nurses working in case management are constantly working on finding new ways to meet the needs of patients.
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