¶ … Discharge Plan Assessment of the Situation

As a case manager for patient in this case scenario there are at least four easily identifiable healthcare issues associated with the discharge of patient; 1. Patient safety related to second floor placement of apartment and navigation of two flights of stairs with walker while using pain medication and recovery time needed for hip replacement 2. Patient safety with regard to size and condition of apartment with limited room to navigate with walker, cluttered space and rug placement all of which are barriers to proper use of walker and ambulation an essential aspect of recovery, 3. The potential for patient non-compliance with new medication regimen for diabetes and dietary plan for weight and glucose control 4. Patient well being with regard to isolation and the inability to follow normal routines such as helping in bakery (two flights down) eating in bakery and interacting with others during recovery (Byers-Lang & McCall, 1993).

b. These issues are crucial when planning for a patient discharge, especially given the nature of the individuals, injury which was brought on likely by some ill health and the individual navigating the two possibly three flights of stairs needed to take out trash from the apartment. The injury itself and the nature of the extended recovery time and need for physical therapy and ambulation make the apartment a poor choice for recovery. Additionally, there are innate issues with regard to the potential for limited social interactions due to apartment isolation and family (caregiver) restraints. Some of these issues could be mitigated with in home care from a visiting nurse and a nursing aide but transferring patient safely to and from the ground floor to eliminate social isolation on a daily basis would not be feasible for a nursing aide as the patients size and the layout and size of the apartment stairways, as well as the compromised health and ambulatory ability of the patient would exclude this option from a care plan for safety reasons. Therefore many issues associated with positive recovery outcomes would be lacking and a discharge to home would not be recommended until after a period of rehabilitation that would allow the patient to safely and independently navigate his stairway.

c. A five team member interdisciplinary team to help determine the appropriate discharge for this patient would include the case manager, hospital social worker, a hospital rehabilitation specialist, the patient's discharge nurse and his primary care physician.

d. The case manager (discharge specialist) would produce the assessment documentation and gather as much information as possible, disseminate it to others on the team. This would include a site visit to the home if description of home is believed to be insufficient and to make recommendations for effective interventions in the home if home discharge becomes the only option. The case manager would also be responsible for communication between the team members and setting meeting times if they are needed for both the team and the patient and family to explain the discharge plan and evaluate further needs for communication and action. The hospital social worker would be given all pertinent information including assessment from case manager, site visit results, insurance coverage information (including plan coverage for alternative of home placement and/or home health care coverage) and family commitment of care for alternatives offered. The social worker would then research options for the patient, which would include cost and availability (available beds in local rehabilitation center or long-term care center). The social worker would also do follow up 1 week, 2 weeks, 4 weeks and 6 weeks post discharge to make further recommendations where needed for a change in the patients needs. The rehabilitation specialist would be given the same assessment as well as site visit results and meet with the patient to assess his post-surgical ambulatory ability, range of motion and ability to self-manage braces and surgical wound care and overall care for himself immediately and over a period of six weeks...

The patients discharge nurse would be responsible, with other team members to provide a brief assessment with recommendations as well as an assessment of any patient or family that would have impact on a discharge plan and offer a final recommendation based on patient interaction and limited review of assessment material. Lastly, the discharge nurse (in company with Case Manger and Social Worker if needed) will explain the discharge plan recommendations and alternatives to the patient and family, along with providing post-discharge safety literature (Merten et al. 2011). The patient's primary care provider will be asked to review health data and assessment information and utilize his or her knowledge of the patient and family over the long-term to determine a recommendation for discharge (as the patient has not sought medical care for 10 years prior to event this could be limited) and then follow up with patient after discharge. Describe the role expected from each identify team member.
II. Analysis of issues from the safety assessment that could affect determination of discharge placement

1. Patient safety related to second floor placement of apartment and navigation of two flights of stairs with walker while using pain medication and recovery time needed for hip replacement. This possible healthcare complication is pervasive and may make the difference between home placement or rehabilitation placement, possibly over the long-term (French et al., 2008) 2. Patient safety with regard to size and condition of apartment with limited room to navigate with walker, cluttered space and rug placement all of which are barriers to proper use of walker and ambulation an essential aspect of recovery. Some of these issues can be mitigated by family intervention, though again the second story placement of apartment is not mutable (French et al. 2008) (Merten et al. 2011) 3. The potential for patient non-compliance with new medication regimen for diabetes and dietary plan for weight and glucose control. The family and patient seem to be poorly informed regarding the seriousness of diabetes and its implications and therefore seem to need intervention to come to terms with the reality of the treatment the patient needs with regard to medication and lifestyle change (French et al., 2008). 4. Patient well being with regard to isolation and the inability to follow normal routines such as helping in bakery (two flights down) eating in bakery and interacting with others during recovery (Byers-Lang & McCall, 1993). Social interaction, perceived community and vocational involvement as well as patient's perceived autonomy are all influential to successful physical and emotional recovery after a debilitating health crisis (Borg, Hallberg & Blomqvist, 2006).

III. Discharge plan

The family and patient explanations will include both a family meeting and a collective meeting where the family is offered the entire assessment of information to realistically look at the possible healthcare complications associated with a discharge to home, as well as recommendations of all team members. The second meeting will take place with the family and the patient to help the family and patient understand the discharge recommendations and why they are recommended.

The family will be offered a complete explanation of the care demands of the patient, including bandage change, ambulatory assistance, personal care needs assistance, cooking and cleaning assistance as well as all the home interventions that would be needed for a home discharge. The family will then be offered the information from the social worker with regard to possible alternatives including a skilled rehabilitation center, and its benefits as well as a long-term care center after rehabilitation care placement for the remaining weeks of support care. Explaining to the family and patient that success is much more likely if the treatment plan is…