English to Portuguese Medical Other

III. SYSTEM ASSESSMENT. It is important to know how a facility functions, who assumes responsibility for various components of discharge planning, and how communication is carried out. Enough cannot be said about the need for consistency in care providers during the discharge process. Effective relationships with the family, as well as a health care team that is familiar with an infant, will help immensely with concise communication and will enhance an organized discharge process. Identifying payer coverage early promotes timely assessment of contractual requirements.
A. A physician or nurse practitioner is responsible for daily management of care.
In teaching institutions where staff rotates, families may need to adjust to many different providers. For those infants with complex issues, identifying a primary attending physician or practitioner provides the family with more continuity. The team then can coordinate, implement, and evaluate the developed care plan.
B. The infant’s primary nurse and nursing team follows the family through the NICU stay coordinating, implementing, and evaluating the developed care plan on a daily basis.
C. Respiratory, physical, and occupational therapists teach families necessary specific skills and assist in transitioning care to community resources.
D. Social workers assess and support the family. Social work should be a part of family and team meetings to help facilitate communication with the family.
E. In the hospital, case manager/patient care coordinator gathers the necessary insurance coverage, sets up the homecare systems (i.e., Visiting Nurse Association [VNA], Medical Supply Company, Early Intervention Referral), and blocked hours if approved by the insurance company. The NICU case managers are the key contact in working with services and insurance companies to secure prior authorizations for exceptions to benefits, equipment, and ambulances.
F. The role of a discharge coordinator or planner varies by institution. The discharge planner can assist in identifying infants who may be approaching discharge, discuss alternatives to home if necessary, and can work with the medical and nursing teams to ensure that the family receives discharge planning in a timely and organized manner.