Howard County Home Health and Hospice



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Policy and Procedure Manual

Discharge/Hold Policy

“Agency Name” will not discharge patients from care because of inability to pay for services. Discharge planning for every Home Health patient will begin upon admission to services. The discharge planning process will include the patient, patient’s physician, significant other, and Agency staff members.

At each recertification period and at any time it is felt that the patient may be no longer appropriate for home/hospice care, the Team Leaders for Home Health or the Hospice team for hospice patients will reassess the patient’s continued eligibility for care. All the criteria, which apply to acceptance and non-acceptance, apply to a decision to discontinue care and discharge the patient. If at that time, or at any time, it is determined that the patient is no longer appropriate for care, they are discharged. In addition, patients will be discharged when the goals of their plan of care have been achieved to the extent possible given services ordered and available.

A Hospice patient may be discharged for the following reasons:

1. The patient is no longer appropriate for Hospice care

2. Patient/family and/or physician decide to discontinue Hospice services

3. Move or transfer out of the service area

4. Death

A home health patient may remain open to the Agency for a period equal to the current certification/recertification period for which there are physician orders. This may be altered due to a hospitalization continued beyond the certification period or any other absence that makes the patient unavailable to the Agency. At the time a patient enters a hospital, SNF, or ICF facility, an OASIS MO100 #6 will be completed. These patients will be considered discharged from services if they remain in the facility after the end of their current certification period. The only exceptions would be:

• transfer to hospice (OASIS MO100 #9 Discharge from Agency)

• death (OASIS MO100 #8 Death at Home)

• patient elected transfer to another agency (OASIS MO100 #9 Discharge from Agency)

• discharge due to goals being met (OASIS MO100 #9 Discharge from Agency)

• discharge due to safety, abuse or non-compliance issues (OASIS MO100 #9 Discharge from Agency)

• no longer meets homebound criteria or other admission criteria (OASIS MO100 #9 Discharge from Agency)

• patient and/or physician request discontinuation (OASIS MO100 #9 Discharge from Agency)

For these exceptions, the patient would be discharged before the end of the certification period.

If the patient resumes home care services after the through date of the certification period, the patient must be discharged from the Agency and readmitted under a new start of care date.

Upon a finding to discontinue or reduce care to the patient, Agency will notify the patient, any family member or other person responsible for the patient, and the patient’s physician, as appropriate, as soon as the decision is made. The notification will include the reason(s) for discontinuance or reduction and, in the case of reduction, the nature of the reduction. Effective dates also will be included. Documentation of the verbal notice and a copy of the written notice will be placed in the patient’s medical record. In advance to the discontinuance of service, due to the patient no longer meeting Medicare guidelines for services, they still have frequency and duration orders for services and their physician does not order discharge from services, an Advance Beneficiary Notice will be issued, informing the patient when they will become financially responsible for services. Agency will follow Medicare guidelines for issuance of the ABN. The patient will be offered a choice of self-pay or discharge from services.

Patients deemed unsafe for in-home care are provided with information about alternatives to home health care. If the patient chooses to seek alternative care, the organization provides continued care until arrangements are finalized. If the patient refuses to seek alternative care, the situation will be discussed with the Administrator and the following steps will be taken:

a. After obtaining the patient’s approval, a staff member notifies the next of kin or the person listed as emergency contact in the absence of the next of kin.

b. A staff member contacts Division of Aging.

c. For patients who continue to refuse alternative care, the Administrator is responsible for serving the patient with official notice within the guidelines of the Agency’s legal counsel.

In both discontinuance and reduction situations, Agency will advise the patient or patient’s family of any available providers or other resources which might provide the care which has been discontinued or reduced. Where discontinuance is the result of patient ineligibility or non-coverage under the designated payor source(s), for medical reasons, or due to Agency safety concerns, services will be discontinued upon Agency making this finding. In non-coverage and ineligibility cases, the patient will be given the option to self-pay for services.

Upon a finding of discharge, Agency will notify the patient, any family member or other person responsible for the patient, and the patient’s physician, as appropriate, of its intent to discharge at least 3 days prior to the scheduled discharge date. If there are reasons to discontinue or reduce service prior to the discharge date, notice of these actions will be made at the same time, following the above procedure. This notification will be documented in the patient record.

For patients requiring continuing care, the discharging nurse and/or the Assistant Administrator will provide assistance in making arrangements for services to be provided after discharge. The discharging nurse and/or Assistant Administrator will provide information relevant to ongoing patient needs when other agencies or care providers are involved after discharge. This information will include, but not be limited to:

1. Reason for transfer and/or discharge.

2. Physical and psychosocial status of the patient at the time of transfer.

3. Summary of the care and/or services provided and progress toward achieving goals.

4. Instruction provided to the patient.

5. Existence of Advanced Directives or a Do Not Resuscitate order.

1. Referrals made to other sources for continued care.

2. The Agency’s communication with patient, caregiver and physician.

During the time between the initial notice of intent to discharge and the patient’s scheduled discharge date, Agency will have an appropriate staff person discuss with the patient and other appropriate persons what options may be available for the patient’s resumption of care with Agency or another available provider(s). Documentation of notice will be placed in the patient’s medical record.

The Patient Care Coordinator or specified Hospice team member will facilitate the hospice discharge process between the patient, family, Attending Physician, Medical Director and any other agency as appropriate. The Team Leader or Assistant Administrator will facilitate the home health discharge process between the patient, family, physician and any other agency as appropriate. The patient’s and/or patient’s family’s continuing care needs will be assessed at discharged and the patient and/or patient’s family are referred to the appropriate resources. This process will be documented, which will include documented notice to the physician of discharge from services.

An RN will complete a written discharge summary when a patient is discharged from services and reasons for discharge. The Patient Care Coordinator or designated RN will complete the Death/Discharge Summary when the patient dies. All documentation will be complete and filed for a discharged patient within 14 days of discharge.

The patient record of each discharged patient will include a discharge summary, which will be completed within seven (7) days of the patient’s discharge from services. The summary will document at least, but not limited to:

1. Date of discharge.

2. Reason for discharge.

3. Status of problems identified throughout the course of care.

4. Patient’s overall status.

5. Summary of care or services provided.

The summary will be documented on an interim order form and the original form is sent to the patient’s physician for his or her signature. When the signed summary is returned to the Agency, it will be filed as a permanent record in the patient’s record.

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