COE Discharge Planning - JHF

September 24, 2025

Members of the care team will gain practical information to assist with discharge planning, including the criteria for transitioning clients out of enhanced care management, strategies for effective documentation and linking care plan goals, assessing client readiness, and tactics to develop or refine discharge plans that support continuity of care and provide clients with connection to long term supports.

Agenda:

  1. Introduction
  2. Fidelity Guidelines and Discharge Planning
    1. Guiding principles connection (DHS, 2024).
    2. Emphasis on fidelity to the COE model.
    3. Discharge policy and documentation requirements.
    4. Importance of discharge planning.
  3. Recovery-Oriented Perspectives on Discharge
    1. Compassion, personal growth, and client empowerment.
    2. Discharge as a transition, not an endpoint.
    3. Promoting independence while respecting unique recovery paths.
    4. Role of safety planning and minimizing unnecessary emergency services.
  4. The Role of Discharge
    1. Flexible discharge criteria.
    2. Focus on client readiness and support.
  5. Discharge Criteria
    1. Plan for reentry if incarceration or housing instability is a factor.
    2. Involve peers in planning.
    3. Support client autonomy and equity.
  6. Southwestern Pennsylvania Human Services (SPHS) COE model.
    1. Core elements: Trauma-informed care, recovery focus, crisis response, assertive community engagement.
  7. Foundations of Discharge Planning
    1. Indicators of readiness.
    2. Challenges in discharge oversight.
    3. Balancing client readiness with staff expectations.
  8. Case Study
  9. Key Takeaways
    1. Discharge planning is a critical transition.
    2. Requires careful planning, flexibility, and alignment with fidelity guidelines.
    3. Supports both client well-being and care team sustainability.

 

Target Audience

  • Nurse
  • Physician
  • Social Worker

Learning Objectives

1. List the criteria for transitioning clients out of enhanced care management.
2. Discuss the importance of documenting readiness for discharge and linking care plan goals to discharge planning.
3. Apply practical strategies to assess client readiness for discharge from enhanced care management.
4. Develop or refine discharge plans that support continuity of care and connect clients to long-term supports.

 

 

Additional Information

AttachmentSize
File Audience Disclosure slides (1.25)_76.pptx51.53 KB
File Discharge Planning Objectives Agenda and References (2).docx34.21 KB
Course summary
Available credit: 
  • 1.25 AMA PRA Category 1 Credit™
    The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
  • 1.25 ANCC
    UPMC Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
  • 1.25 ASWB
  • 1.25 Attendance
Course opens: 
09/24/2025
Course expires: 
12/31/2025
Event starts: 
09/24/2025 - 12:00pm EDT
Event ends: 
09/24/2025 - 1:30pm EDT
Add to calendar: 

Members of the care team will gain practical information to assist with discharge planning, including the criteria for transitioning clients out of enhanced care management, strategies for effective documentation and linking care plan goals, assessing client readiness, and tactics to develop or refine discharge plans that support continuity of care and provide clients with connection to long term supports.

Agenda:

  1. Introduction
  2. Fidelity Guidelines and Discharge Planning
    1. Guiding principles connection (DHS, 2024).
    2. Emphasis on fidelity to the COE model.
    3. Discharge policy and documentation requirements.
    4. Importance of discharge planning.
  3. Recovery-Oriented Perspectives on Discharge
    1. Compassion, personal growth, and client empowerment.
    2. Discharge as a transition, not an endpoint.
    3. Promoting independence while respecting unique recovery paths.
    4. Role of safety planning and minimizing unnecessary emergency services.
  4. The Role of Discharge
    1. Flexible discharge criteria.
    2. Focus on client readiness and support.
  5. Discharge Criteria
    1. Plan for reentry if incarceration or housing instability is a factor.
    2. Involve peers in planning.
    3. Support client autonomy and equity.
  6. Southwestern Pennsylvania Human Services (SPHS) COE model.
    1. Core elements: Trauma-informed care, recovery focus, crisis response, assertive community engagement.
  7. Foundations of Discharge Planning
    1. Indicators of readiness.
    2. Challenges in discharge oversight.
    3. Balancing client readiness with staff expectations.
  8. Case Study
  9. Key Takeaways
    1. Discharge planning is a critical transition.
    2. Requires careful planning, flexibility, and alignment with fidelity guidelines.
    3. Supports both client well-being and care team sustainability.
Zoom Meeting
Pittsburgh, PA
United States

Lori Helisek

Cheryld Emala

 

In support of improving patient care, this activity has been planned and implemented by the University of Pittsburgh and The Jewish Healthcare Foundation. The University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
As a Jointly Accredited Organization, University of Pittsburgh is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. University of Pittsburgh maintains responsibility for this course. Social workers completing this course receive 1.25 continuing education credits.

Physician (CME)
The University of Pittsburgh designates this live activity for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nursing (CNE)
The maximum number of hours awarded for this Continuing Nursing Education activity is 1.25 contact hours.

Social Work (ASWB)
The maximum number of hours awarded for this Continuing Social Work Education activity is 1.25 contact hours.

Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.

Available Credit

  • 1.25 AMA PRA Category 1 Credit™
    The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
  • 1.25 ANCC
    UPMC Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
  • 1.25 ASWB
  • 1.25 Attendance
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