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Discharge Planning and Transitions of Care

Sets out how the Agency plans for each patient’s discharge from the start of care, helps patients choose a post-acute provider using quality and resource use data, sends the receiving provider or practitioner the information needed for a safe transition, and completes and sends discharge and transfer summaries on time.

Preview: full text with a package
About this policy
Policy number
TX-HH-DC-01
Version
1.0
Main rule
42 CFR §484.58
Library
Texas home health · 56 policies
Category
Service delivery
Sections
17

In short

  • Start planning for discharge at the first visit, and teach the patient and caregiver what they need to manage on their own.
  • If a patient is moving to another home health agency or to a nursing, rehabilitation, or long-term care hospital, give them a list of options with quality data and let them choose.
  • Send the receiving provider the information they need for safe care, including medications and the patient’s goals and wishes.
  • Discharge summary: to the primary care practitioner within 5 business days. Transfer summary: within 2 business days of a planned transfer, or of learning of an unplanned one.
  • Answer requests from the receiving provider for more information promptly.

What's inside

17 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (42 CFR §484.58)
  • 5. Planning for Discharge From the Start of Care
  • 6. Helping the Patient Choose a Post-Acute Provider
  • 7. Information Sent to the Receiving Provider
  • 8. Discharge and Transfer Summaries
  • 9. Assessments at Transfer and Discharge
  • 10. Responsibilities
  • 11. Records and Compliance Monitoring
  • 12. Staff Training
  • 13. References
  • 14. Related Policies and Forms
  • 15. Approval
  • 16. Revision History

An inspector may ask

  • Show me where discharge planning started for this patient.
  • This patient went to a skilled nursing facility. How did you help her choose one, and what data did you share?

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