The government has established a Discharge Planning Program to help active duty and retired service members and their families to understand and access the healthcare system.  At Womack Army Medical Center, the Discharge Planners are available on the second floor and on the in-patient wards.

DEFINITION:

Discharge Planning is the quality link between hospitals, community-based services, non-government organizations and caregivers.

Effective Discharge Planning supports the continuity of healthcare, between the health care setting and the community, based on the individual needs of the patient. It is described as “the critical link between treatment received in hospital by the patient, and post-discharge care provided in the community.”¹

1. NSW Department of Health, Discharge Planning Principles, 2005

THE ROLE OF THE INPATIENT CASE MANAGER [DISCHARGE PLANNER]

Inpatient Case Managers [Discharge Planners] are registered nurses who work with the medical staff and the patient to arrange extended care at home or in the community prior to discharge from the hospital. The discharge planner functions as a consultant for the discharge planning process within a health facility, providing education and support to hospital staff in the development and implementation of discharge plans. Discharge Planners coordinate all services that will allow patients to smoothly transition to the next level of care while keeping costs to the patient at a minimum.

**DISCHARGE PLANNERS DO NOT MAKE DIAGNOSIS OR TREATMENT DECISIONS.

The Discharge Planner will assess a patient’s needs; create a plan of care; educate the patient and their family, and help the individual to make the best decisions they can about their healthcare needs prior to hospital discharge.

Discharge planning may be helpful if you have:

• Chronic or multiple health problems
• A serious or terminal illness
• More than one Provider for different specialties
• Lack of family or community support
• Difficulty following your Provider's plan of care

Discharge Planners may assist you in obtaining:

• Home Health Services
• Hospice Services
• Occupational, Physical or Speech Therapy Services
• Medical equipment, i.e. wheelchairs, oxygen, etc
• Use of the TRICARE/Health Net  system
  

INPATIENT CASE MANAGEMENT/DISCHARGE PLANNING SERVICES

Your Provider, the leader of your health care team, works closely with your Discharge Planner to ensure that patients move onto another level of care whether it is:

• home care
• out-patient care
• alternate acute care
• long term acute care
• nursing home care

Discharge Planners are available in the following inpatient areas:

• ICU/SDU
• NICU
• 3 North - Pediatrics
• 3 South - Mother/Baby Unit
• 4 South - Medicine
• 2 North - Surgery
• 6 South - Psychiatry