{"ref":"MI-HH-DC-01","title":"Discharge Planning, Transfer and Discharge Summaries","category":"Service delivery","summary":"Sets out the Agency's discharge planning process from admission onward, how it helps patients who transfer to another home health agency or are discharged to a skilled nursing facility, inpatient rehabilitation facility or long-term care hospital choose a provider using quality and resource use data, what information it sends to the receiving facility or practitioner, and the deadlines for the discharge summary (within 5 business days of discharge) and the transfer summary (within 2 business days of a planned transfer, or of learning of an unplanned transfer). It adds the Michigan Medicaid duty to develop a transfer or discharge plan at admission and to ensure continuity with Home Help and MI Choice.","inShort":["Start planning discharge at admission and review the plan at every recertification.","If a patient moves to another agency or to a nursing or rehab facility, share quality data and let the patient choose.","Send the discharge summary to the primary care practitioner within 5 business days of discharge.","Send the transfer summary within 2 business days of a planned transfer, or of learning of an unplanned one.","Tell the clinical manager the same day you learn a patient went to the hospital."],"primaryCitation":"42 CFR §484.58","citations":["Michigan Medicaid Provider Manual, Home Health, Sections 4, 5 and 11"],"federalCitations":["42 CFR §484.58","42 CFR §484.110(a)(5)","42 CFR §484.110(a)(6)","42 CFR §484.60(c)(3)(ii)","42 CFR §484.60(a)(2)(xiii)","42 CFR §484.55(d)(3)"],"surveyorAsks":["When did discharge planning start for this patient? Show me where it is in the plan of care.","This patient went to a skilled nursing facility. How did you help the patient choose the facility, and what data did you share?"],"forms":[{"ref":"MI-HH-DC-01-A","title":"Transfer or Discharge Summary"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.58)","5. Discharge Planning From Admission","6. Helping the Patient Choose a Post-Acute Provider","7. Discharge and Transfer Summaries","8. Learning of an Unplanned Transfer","9. At Discharge","10. Michigan Medicaid: Continuity With Other Programs","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"mi-hha","state":"Michigan","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}