All patients recieving Home Health services should have a goal-based discharge plan created on the day of Admission. Stories of citations and survey deficiency are being told by agencies large and small who are not following the CMS guidelines for care delivery. Every patient should have a discharge plan created within 5 days of the Admission. The single biggest reason for rehospitalization is unclear expectations by the patient unit and a lack of a care plan with defined goals.
Patients/Caregivers must be involved in the creation of their care plan. Clear goals must be developed and the patient and caregiver involvement documented.
For Home Health patients:
- Is the trajectory to discharge planned and documented?
- What are their expectations?
- What improvement measures will the agency monitor?
- Is the patient’s progress toward goals documented at EVERY visit?
- Do you use a roadmap with the patient to guide them on the journey to self-care?
- Are the goals set realistic?
- Do you show collaboration across disciplines for the discharge?
- Do you document to teach back processes to ensure patients/caregivers understand the teaching given to them?
- As discharge looms do you hold a care conference with the patient unit and the clinicians?
- Does the patient unit have the right equipment, supplies, and medications on hand at discharge?