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Discharge Visit Requirements?? Help

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by pennyrwalker pennyrwalker (New) New

Please describe the process your agency has in place for discharges. Specifically for a discharge visit for pts that are being discharged d/t being no longer hospice appropriate/no longer terminally ill. I am very interested in how other agencies do this. I can not find any Medicare regulations on exactly how this process is supposed to work in regards to whether the pt is supposed to have a visit on the day of discharge, and who is to make said visit. RN? LVN? Thanks for input!

Penny RN

toomuchbaloney

Has 43 years experience.

The team determines that the patient will be discharged it often results after a number of IDT meetings. A date for is generally agreed upon during the IDT.

When the official order is received from the medical provider the team executes the DC POC that they had been developing.

The case nurse and MSW will already have been discussing this potential and then plan for discharge with the patient and family. One or both of them will visit as needed to finalize the arrangements for post discharge care. Check your state laws but in many states either the MSW or the RN can witness appropriate signatures.

Does this answer your question?

Did I leave anything out?

QuiltDog

Specializes in Hospice Nursing.

I would agree - this is something that should not be a surprise to the patient/family and should be planned for. The team needs to make arrangements for any meds/DME that hospice will no longer be covering.

As the other posters stated, it can be a long process. The discharge must be safe, so you need to be sure that they have another source for DME (often that it is already in the house), they have plenty of meds, they have a referral to an MD if needed . . . There is a "discharge letter" that needs to be given some days in advance which gives information on appeal rights, and we ask the POA or patient to sign it to acknowledge receipt but occasionally you get someone that disagrees with the decision and refuses. That does not impact the fact of the discharge though.

ktwlpn, LPN, RN

Specializes in Med Surg, Homecare, Hospice.

How do you (or do you) keep in touch with former patients ,especially ones living in LTC or AL? Do you call them,do you ask the nursing home staff for updates?

We generally don't. If it is a nursing home patient we may have our palliative group see them.

ktwlpn, LPN, RN

Specializes in Med Surg, Homecare, Hospice.

I'm in an LTC and we have a consulting hospice who has "graduated" an alarming number of residents.I suspect they are picking them up too soon to make their monthly referral quota and that's a bad practice in my opinion. I hate to see the family go through that. And now they are up my butt wanting updates all of the time.It's driving me nuts

toomuchbaloney

Has 43 years experience.

There is no reason for the hospice agency or staff to require updates on patients who are not under their care, in fact, providing medical information without the consent of the patient or DPOA could well be a HIPAA violation. IMV

Edited by toomuchbaloney