2008 Conference

Planning Committee

The conference held on September 24, 2008 was a success. Over 340 participants from across the continuum of care attended. The evaluations indicated that 94% of the attendees rated the program from good to excellent.

Picture of the Planning Committee

"Person-Centered Transitions of Care: Challenges and Successes for Discharge Planning Across the Continuum" Conference Planning Committee: back, l to r, Elliott Frost, NYAHSA, Lisa Newcomb, ESAALF, Andy Koski and Lynda Schoonbeek, NYSHCA, Sara Butterfield, IPRO, Margaret Clark, HCP of NYS, seated, Nancy Leveille, NYSHFA, Anna Colello, Esq, NYSDOH, Anita Russo, ESAALF, missing, Deb LeBarron, HANYS, Scott Jackson, NYSHFA. Photo credit: Mike Wren

Discharge Planning Safety Considerations

Safety Concerns that Impact an Individual Wishing to Live in the Community

Individual Capacity Issues

  • Competence and decision making capacity of the person
  • Ability of the person to self-direct
  • Non-compliance
  • Balance – frequent falling
  • Memory impairment
  • Self-medication
  • Sensory deficits
  • Unstable clinical condition
  • Mental health concerns
  • Lack of education e.g. affecting ability to read instructions

Environmental Issues

  • Unsafe housing
  • Lives alone
  • Lack of support
  • Lack of understanding of individual's situation
  • Homelessness, housing availability and accessibility

Provision of Service Issues

  • Geographic location
  • Availability of services as a factor in determining discharge potential
  • Lack of transportation
  • Lack of equipment and supplies at home
  • Drug and alcohol abuse
  • Criminal activity
  • Costs of services and perceptions of costs
  • Funding constraints and inadequate financial resources.
  • Insurance coverage (individual's assumption of risk may affect scope of coverage)
  • Potential abuse in home
  • Inappropriate use of resources
  • Fear of raising issues/concerns earlier
  • Language/cultural barriers
  • Refusal to accept services
  • Definition of safety
  • Medical perspective of safety needs
  • Perception - actual liability concerns
  • Interpretation of standards/regulations
  • Fear of litigation
  • Safety of aides – have aides been exposed to criminal behavior or sexual harassment while on the job in this person's home in the past?
  • Lack of coordination between discharge planner and home care agency concerning acceptance/capacity
  • Consideration of the facts of a "difficult patient's" care before determining Home Care Agency's compliance with regulation

Key Elements for Effective and Safe Discharge Planning to Facilitate An Individual's Right to Choose

Policy Elements

  • Clear policies and protocols for managing and directing the practice of discharge planning
  • High risk identification process that functions as a problem solving forum and resource coordination manager supported by the highest level of administration that engages all the players (e.g. Case Management, Social Worker, Administration, Legal, Risk Management, ethics, business, Chaplain, financial, external agencies)
  • Early planning and intervention to identify/discuss safety issues in order to make the necessary linkages with community services
  • Ability of the home care agency to implement accessible flexible staffing
  • Electronic HIPAA compliant uniform record sharing among stakeholders with standardized policies and protocols to guide the exchange of information
  • Shared knowledge base that informs discharge planners concerning safety issues and solutions
  • Established standards for discharge planning throughout a continuum of care at home based on: education; accountability; individual choice and peer support
  • Consolidated/accessible/current database of resource information designed to educate and inform professionals about available resources
  • Standards to establish uniform practices for the exchange of discharge information
  • Establish relationships with local resources including adult/child protective service agencies
  • Discharge and service plans that are realistic and attainable in a reasonable time frame with available resources
  • The availability of a 24/7 care management safety net
  • Recognition/acknowledgement of individual's rights and informs persons of their rights applied to the discharge planning process and educates persons about service options, financial options, etc.

Process Elements

  • A person centered assessment process that is proactive and careful in assessing problems/concerns
  • A person centered assessment process that focuses on the person's strengths vs. deficits to ensure consumer directed care and control
  • Communication and coordination among formal and informal caregivers and stakeholders that is designed to mobilize resources and identify potential solutions
  • Engagement and support from the multi-interdisciplinary team including physicians
  • Collaboration with community advocates concerning safety issues and solutions as needed
  • Utilization of peer support to prepare persons for transition between levels of care and to help sustain persons in the least restrictive setting