Complex Discharge Coordination Note – Sunrise Clinical Manager Patient Name: Michael Anderson MRN: 00794325 Age: 60 years Admit Date: 10/03/2025 Discharge Date: 10/14/2025 Attending Physician: Dr. Priya Desai Case Manager: Laura Bennett, RN, BSN, CCM Admitting Diagnosis: Right Hip Fracture, s/p Open Reduction and Internal Fixation (ORIF) Discharge Diagnosis: Same Clinical Summary Patient admitted following mechanical fall at home resulting in right hip fracture. Underwent ORIF on 10/04/2025. Postoperative course stable; pain managed with oral analgesics. Physical Therapy and Occupational Therapy recommend transfer to inpatient rehabilitation for continued strengthening, mobility, and ADL support. Medically stable for discharge today. Discharge Disposition Destination: Acute Inpatient Rehabilitation Facility Facility Name: Valley Rehabilitation Center Facility Contact: Admissions Coordinator – Jessica Reed, RN Phone: (555) 234-7789 Bed Availability: Confirmed for 10/14/2025 Transportation: Basic Life Support (BLS) ambulance arranged via MedTrans; pickup at 15:00 Insurance / Authorization Payer: Blue Cross PPO Authorization Required: Yes Authorization Number: BC-2025-RX4312 Valid Dates: 10/14/2025 – 10/21/2025 Approved Level of Care: Acute Rehabilitation (3 hours/day therapy) Concurrent Review: Facility to provide clinical updates to payer every 3 days Social / Support Lives with spouse in two-story home; currently unable to navigate stairs safely. Spouse supportive and agreeable with rehab plan. Family updated on discharge time and facility address. Durable Medical Equipment (DME) Patient will require walker and shower chair upon return home (to be arranged by rehab facility prior to discharge from rehab). Follow-Up Appointments Orthopedic Surgery follow-up: 2 weeks post-rehab discharge Primary Care: Within 7 days of rehab discharge Education / Discharge Instructions Reviewed plan of care, reason for rehab transfer, and anticipated length of stay. Discussed insurance coverage and potential copay obligations; patient verbalized understanding. Provided written discharge summary and transfer packet including medication list, operative note, therapy progress, and most recent labs. Encouraged to maintain communication with case management if discharge plans change. Barriers to Discharge ☑ Insurance authorization — obtained ☑ Facility placement — confirmed ☐ Transportation — scheduled and verified ☐ Medication coverage — no issues reported ☐ Home environment — not safe for immediate return Care Coordination Activities Initiated and submitted clinical packet to Blue Cross for authorization (approved 10/13/2025). Communicated with Valley Rehab regarding patient needs, mobility status, and equipment. Updated attending physician and bedside nurse on transfer plan. Confirmed discharge summary and medication reconciliation completed in SCM. Faxed required documentation (H&P, MAR, therapy notes) to receiving facility. Informed family of pickup time and provided facility contact information. Final Plan / Outcome Patient medically stable for transfer to Valley Rehabilitation Center for continued therapy. All authorizations and transportation arrangements completed. Family aware and in agreement with discharge plan. Handoff report communicated to receiving RN. Signature: Laura Bennett, RN, BSN, CCM Case Manager 10/14/2025 12:40