Many patients who are discharged from hospital will have ongoing care needs that … Wound Care: If a wound is involved, the patient will need skilled and timely wound care. This We understand that the resident has a right to receive the needed long term care services in the least restrictive and most integrated setting. I. [ Microsoft Word version - 720.52 KB; PDF version - 188.59 KB] Be Prepared to Go Home Checklist … “The IMPACT Act created a new requirement that hospitals use quality data during the discharge planning process and provide it to beneficiaries. Discharge Planning After Surgery Once you meet the discharge criteria specified for your type of surgery, you will be released to go home or be transferred to a room. Have you (and your caregiver) been trained on how to care for your special needs? Your health Ask the staff about your health condition and what you can do to get better. Health care professional(s) and the patient or resident participate in discharge planning activities. Although CMS is calling for patients to be given more information about post-acute care options following a hospital stay, it is still maintaining its commitment to anti-steering regulations. Be realistic about the goals and expectations, bearing in mind that rehab will continue in the home setting and later as an outpatient in the community. It also should include information on whether the patient ʼ s condition is likely to improve; what activities he or she might need help with; information on medications and diet; what extra equipment might be needed, such as a wheelchair, commode, or oxygen; who will handle meal preparation, transportation and chores; and possibly referral to home care services. poor patient outcomes, and caregiver stress. Officials from the National Association for Home Care & Hospice (NAHC) called the rule “expected,” adding that it implements requirements outlined in the IMPACT Act. What type of equipment will you need? You Your family member. Have you been told about community benefits and services (like meals on wheels), and how to get them? If you know someone who may benefit from private duty care, we invite you to call Sonas Home Health Care today and request information. Have you been set up with a durable medical equipment (DME) provider? Ask about problems to watch for and what to do about them. Have you contacted public utilities (such as electricity, water, etc.) specifically trained or certified in ostomy care. Receive industry updates and breaking news from HHCN, Medicare Payment Advisory Commission (MedPAC) findings, The Centers for Medicare and Medicaid Services, The National Association for Home Care & Hospice, House Bill Looks to Keep Medicare Sequestration ‘Holiday’ in Place for Home Health Agencies, Others, CMS Announces New Direct-Contracting Model to Promote ‘Easier Access to Home Care’, New Hospital-at-Home Waiver Program Is ‘Another Step Forward’ for Home-Based Care, Nightingale Homecare uses mobile printers to power productivity and improve patient care, 2020 Home Health Care News Outlook Survey and Report, Growing Home Health Admissions and the Bottom Line: A Case Study with Intrepid USA. To help in the planning process, here are a few post-hospital concerns that families need to be prepared to monitor and various daily activities patients often need help with: Transportation: Transportation to and from follow-up and other doctor appointments. A simple med box prefilled with the proper doses can make a significant difference, but it is not always enough to ensure that the patient consistently remembers to take the right medications at the right time. We refer loving and competent caregivers and professional nurses to assist you or your loved one – from providing transportation to and from follow-up appointments, to preparing healthy meals at home. The patient will need social and emotional support to help them stay motivated and engaged in their recovery process. The long-awaited final discharge planning rule, released today, appears to offer some good news for home health agencies. “It represents a step forward in interoperability and the MyHealthEData Initiative.”. Physical Activity Monitoring: Some patients may be inclined to do too much too soon, while others may not be motivated to get up and move around at all. • Address concerns with patient and families soon. The family will need to ensure that appropriate help is provided. leaves a care setting. They also have virtually no control on deciding what information is shared and often find themselves admitting patients lacking key information, hindering their ability to fully understand their status, needed supplies, or how to even conduct meaningful conversations with ot… After reviewing discharge instructions with your doctor, you may realize you have a longer-than-expected recovery time, and you may need additional care from home. “Medicare statute provides beneficiaries with the freedom to choose their PAC provider, and the laws state that hospitals may not recommend providers,” MedPAC senior analyst Evan Christman noted in a March 2018 public meeting. If you need a home health care aid, ask your discharge planner for suggestions. Does your caregiver know how to provide care in the case of an emergency (such as CPR, first aid, or other emergency care)? Friends and relatives may have other obligations such as work or childcare; being able to provide the time and proper care that is needed isn’t always possible. Home Care Tasks Checklist. Under CMS’s newly announced discharge planning rule, patients and their families are required to have access to information that will support them in making informed decisions about their post-acute care (PAC) options, including data on quality measures and data on resource use measures. Rehab-to-Home Discharge Guide . Household care, such as cooking, cleaning, laundry, and shopping; Health care, such as driving to appointments, managing medicines, and using medical equipment ; Depending on the type of help you need, family or friends may be able to assist you. If you need to evacuate after an emergency, have you identified the closest shelter and have you thought about what you need to bring. “If they aren’t handled properly, the unwelcome result is often a costly readmission or poor patient outcome. The patient may need help managing these details as they recover their focus and equilibrium. Do you have prescriptions for all of your medications and services? Practical steps should be taken to minimize fall risks in the home. “This delivers on President Trump’s executive order on promoting health care choice and competition,” CMS Administrator Seema Verma said during a Thursday press call. After reviewing discharge instructions with your doctor, you may realize you have a longer-than-expected recovery time, and you may need additional care from home. Also, a personal attendant may be needed to provide standby assistance for a few days. (2) A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to, hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the … Patients who are discharged from an acute care setting need and deserve to know how they’re transition will be handled. Why Is Good Discharge Planning So … Families often face this dilemma; feeling inadequately prepared for the realities of their loved one’s transition from hospital to home. CMS’ Discharge Planning Rule Supports Interoperability and Patient Preferences. Did you choose a Medicare certified home health care agency? Tracking and analyzing data from your discharge planning checklists, patient well-being assessments, readmittance statistics, and other metrics can be a way to inform your discharge planning process and evaluate discharge programming. If a caregiver will be helping you after discharge, write down their name and phone number. Joyce Famakinwa is a Chicago area native who cut her teeth as a journalist and writer covering the worker’s compensation industry and creating branded content for tech companies and startups. Section 3 Initial Review and Confirmation of Plan of Care - Checklist (SNF & Home Health) Timely Contact Initial visit within 24h of discharge if high-risk patient/ACO patient (i.e., same day admit, IVs) The transition from hospital to home can be challenging as patients and families become responsible for care coordination. For each question, answer if help is needed and indicate how often. “I don’t think that this impacts [anti-steering],” Verma said. 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