Get patients to the next Level of Care in a shortened amount of time, with quality outcomes.
The expectation is that patients will achieve their highest level of function with the support of community resources (eg., Home Care, Outpatient therapy.)
Manage clinical needs and financial implications according to contracted levels.
Pay attention to over and under utilization of therapy.
Negotiate a higher level of care/reimbursement rate if patients can tolerate more therapy.
Goals should be written according to specific prior level of function.
Begin working with patient/ family from day 1 to determine a reasonable and achievable discharge plan.
Drive the d/c date from the time of admission.
Be mindful of the health plan goal = decreased LOS/ next Level of care.
Meet weekly with the clinical team to discuss progress/ barriers to goals.
Discuss the PLOF with the entire team after admission; they may have valuable information to add from discussions with the family.
Address the D/C plan every week to ensure it is reasonable. If not, evaluate alternative options with the patient/ family quickly.
Work with your Administrator to ensure you have assigned one, knowledgeable person to effectively communicate skilled therapy services provided, goals/ barriers, estimated LOS, and the discharge date/ plan weekly with the health plan case manager.