Last Updated on December 29, 2019
Discharge planning is yet another essential function of case managers, support coordinators and social workers. The discharge process is often met with mixed emotions from case managers. The brief sense of relief of having one less case is usually followed by anxiety knowing at some point you’re going to get another one that may be more difficult than the one you just discharged.
In most cases,
discharge means that the client has achieved his or her goals and is no longer
in need of services. This is often the case with mental health case management.
However, intellectual disability (ID) case management is a little different. ID
case management services tend to be long term so discharge from services is usually
the result of major events such as a move to another state or city, or a
transfer to a nursing facility or an ICFIDD. These facilities have their own
case management services and there is no need for additional case management
from community services boards
. In addition, Medicaid views this as a duplicate service and will not pay for
two case management services. The discharge process is critical to ensuring
that your clients have a smooth transition from one service to another.
There are other situations when the client is not compliant
with services and chooses to leave on their own. This is sometimes referred as a
discharge against medical advice or “AMA” discharge. I haven’t seen this one
often in case management but on several occasions while working in the
psychiatric hospital (especially on the substance abuse unit).
There are three basic components to the discharge process: linkage,
service coordination, and documentation. Of course, the discharge process can
vary depending on the agencies policy and procedures.
Linkage
During the discharge process, case managers assist with
referrals to other agencies. This often includes providing the client and/or
the family with a provider list so that they can make informed choices. The
linking process may also include educating families about available resources
without influencing their choices. Case managers may also provide assistance with setting up and attending tours with families.
Service Coordination
The service coordination aspect involves contacting new
providers and exchanging information. This involves contacting agencies in
other states and determining the services that they can offer. The case manager
may also provide social history and any other medical or behavioral health
information to assist with the transition (with written consent of course). When
cases are transferred between neighboring cities, agency directors often
coordinate to prevent gaps in services.
Discharge Documentation
As with any other function of case management, documentation
is also necessary. A discharge summary is completed detailing the progress on
treatment plan goals and reason for discharge. Health, behavioral, and
medication changes during the period of case management services are also documented
in the discharge summary. Recommendations for ongoing and future services as
well as any referrals that were made are also included. After the discharge summary
is complete, the case is then closed but the record may remain with the agency
for five to ten years depending on the agency’s policy. 
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