QAPI Program Utilization_Manual

DISCHARGE PLANNING POLICY Discharge planning is initiated for every Home Health Care’s client following the client’s admission to the Home Health Care Agency. PURPOSE To ensure continuity of care when the client is discharged from the Home Health Care Agency. PROCEDURES 1. The Home Health Care Registered Nurse: a. Assesses the client discharge potential in the initial nursing assessment. b. Documents the client’s discharge potential on a Home Health Care Client Plan of Care form. c. Provides information regarding the client’s discharge potential at a client Case Conference. 2. Client Case Conference participates: a. Discuss the client’s discharge potential based on the Registered Nurse’s information. b. Develop plans for continuity of client’s care. c. Develop and document a plan for continuity of client’s care on the Home Health Care Client Plan of Care form. d. Review the client’s discharge potential and corresponding Plan of Care for necessary revisions and to determine the appropriateness or inappropriateness of the client continuing to receive Home Health Care Services 3. Home Health Care Staff and interdisciplinary team members assist clients regarding their discharge by: a. Consulting with the client and client’s family regarding the need for the client’s discharge from the Home Health Care Agency. b. Serving as a referral source for client and client’s family in obtaining follow- up support services. c. Making and documenting contact with the client and client’s family one (1) week after the client’s discharge from the Home Health Care Agency. d. Documenting discharge/transfer information on the appropriate discharge/transfer forms. e. Consulting with the client and client’s family regarding the provision of discharge information. f. Participating in a conference with the client and client’s family regarding the 46