O-12-950 Discharge Planning Assessment Tipsheet

🎯 Purpose

The goal of home care is to keep our client's out of the hospital during the time we see them and also after we have discharged them. A follow up call after we discharge the client is a tool to utilize to help keep client's out of the hospital.

🔄 Process

The discharge assessment ( __18, __18X) includes a section in the physical assessment titled "Discharge Planning":

The intent of the following question in this section is to identify those clients that may benefit from a follow-up call from Adara after discharge from agency:

Potential criteria to answer "Yes" to this question include:

Client has history/potential of decline
Client has history of repeat admissions
Client has history of multiple hospitalizations
Client has chronic medical comorbidities such as (CHF, Multiple UTI, COPD, CKD, CAD)
Unusual circumstance that may require a call
Client has social instability (such as Hx of discharge against medical advice, homelessness, non-adherence concerns, etc)
Client has a guarded/poor rehabilitation prognosis
Client has met maximal medical improvement but concerns with health status
Client has refused recommendations to continue home care services and clinician is concerned they may re-hospitalize

Refer to clinical process O-13-015 Case Conference regarding decision to discharge versus continue care.

Refer to O-13-104 Discharge Follow-Up for additional details regarding back office follow-up after discharge.

📅 Effective: 04/30/2025 | ✅ Approved by: JM