Discharge Planning, Transfer, and Transition Summaries
Sets out the Agency's discharge planning process from admission onward: helping patients transferred to another home health agency or discharged to a SNF, IRF or LTCH choose a post-acute care provider using quality and resource use data, the steps for a planned discharge, sending all necessary medical information to the receiving provider, the discharge summary within 5 business days of discharge, transfer summaries within 2 business days of a planned or (once known) unplanned transfer, answering requests for more information, and discharge at death.
- Policy number
- MO-HH-DC-01
- Version
- 1.0
- Main rule
- 42 CFR §484.58 (adopted by 19 CSR 30-26.010(1)(A))
- Library
- Missouri home health · 57 policies
- Category
- Service delivery
- Sections
- 19
In short
- Plan for discharge from the first visit, and keep the after-discharge practitioner's contact in the record.
- Help patients choose a nursing facility or another agency using quality data, and respect their choice.
- Send the discharge summary within 5 business days of discharge.
- Send a transfer summary within 2 business days of a planned transfer, or of learning of a hospital admission.
- Tell the case manager the same day if you learn a patient went to the hospital.
What's inside
19 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §484.58; 42 CFR §484.110(a)(5), (6); 19 CSR 30-26.010(1)(A))
- 5. Discharge Planning Starts at Admission
- 6. Choosing a Post-Acute Care Provider
- 7. Planned Discharge
- 8. The Discharge Summary
- 9. Transfer to a Health Care Facility
- 10. Transfer to Another Home Health Agency or to Hospice
- 11. Discharge at Death
- 12. Responsibilities
- 13. Records and Compliance Monitoring
- 14. Staff Training
- 15. References
- 16. Related Policies and Forms
- 17. Approval
- 18. Revision History
An inspector may ask
- Show me the discharge summary for this patient. When was the patient discharged, and when was the summary sent, and to whom?
- This patient went to the hospital. When did you learn of it, and when was the transfer summary sent?
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