Purpose:

To ensure safe, timely, and coordinated transfer of care from hospital, rehabilitation, or skilled nursing facility to the patient’s home, with the goal of reducing avoidable readmissions, improving patient outcomes, and promoting independence.

Scope:

Applies to all agency staff involved in patient intake, skilled nursing, therapy services, personal assistance, and care coordination for patients discharged from an inpatient setting.

 Policy Statement:

Heartsphere Home Care will provide transitional care services in compliance with Texas HCSSA regulations, Medicare Conditions of Participation, and applicable payer requirements. The agency will ensure:

• Prompt post-discharge contact
• A comprehensive medication reconciliation
• Physician communication within required time frames
• Patient/caregiver education on self-management and warning signs
• Follow-up visits as clinically indicated

 Procedure:

1. Referral & Intake

• Receive referral from hospital discharge planner, physician, or facility.
• Gather discharge summary, medication list, therapy notes, and follow-up appointment schedule.
• Verify patient eligibility for home health services and insurance coverage.
• Assign a primary nurse/case manager.

2. Pre-Discharge Coordination

• Contact the hospital/facility nurse to confirm discharge date and needs.
• Coordinate necessary DME (durable medical equipment) delivery before patient arrives home.
• Schedule first home visit within 24–48 hours of discharge (or per payer requirement).

3. Initial Home Visit

• Conduct comprehensive assessment including vitals, wound status, functional ability, pain, and psychosocial needs.
• Perform medication reconciliation, identifying discrepancies and confirming with prescribing provider.
• Review hospital discharge instructions with patient and caregiver.
• Educate on:
• Disease-specific self-management (e.g., CHF, COPD, post-op care)
• Signs/symptoms to report immediately
• Emergency contact procedures

4. Care Plan Development

• Collaborate with physician to create or update the Plan of Care.
• Assign skilled nursing, therapy, and/or personal assistance services as needed.
• Document in the agency EMR within 24 hours of visit.

5. Ongoing Monitoring

• Conduct follow-up visits per care plan.
• Monitor for early signs of decline or complications.
• Communicate changes to the physician promptly.
• Adjust services as needed based on reassessment.

6. Communication & Documentation
7. Maintain secure and timely communication with:

• Referring facility
• Primary care physician/specialist
• Patient’s pharmacy

 

2. Document all contacts, education provided, interventions, and patient/caregiver responses in the clinical record.
3. Discharge from Transitional Care

1. Discharge when:

• Patient meets care goals
• Condition is stable
• Patient transitions to long-term care or self-management

2. Provide written summary to patient, caregiver, and primary care provider.