Discharge Planning Checklist for Skilled Nursing Facility
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Discharge Planning Checklist for Skilled Nursing Facility
1
Identify resident's discharge goals
2
Assess resident's physical health and well-being
3
Review medication regimen
4
Consult with interdisciplinary team
5
Planning appropriate discharge setting
6
Arrange home modifications if necessary
7
Organize required medical equipment for home use
8
Arrange home health services if needed
9
Create a detailed care plan for discharge
10
Discuss care plan with resident and family
11
Approval: Physician Review of Care Plan
12
Coordinate with social services for assistance if needed
13
Schedule follow-up appointments
14
Provide instructions for medication and care at home
15
Train family members on resident's care needs
16
Verify insurance coverage for discharge plan
17
Review transportation needs for discharge
18
Approval: Case Manager Review of Discharge Plan
19
Finalize and document discharge plan
20
Execute discharge plan on the date of discharge
Identify resident's discharge goals
In this task, you will identify the resident's goals for discharge from the skilled nursing facility. This includes understanding what the resident hopes to achieve, any concerns they may have, and their preferences for aftercare. By understanding the resident's goals, we can tailor the discharge plan to meet their individual needs and maximize their chances of successful transition back into the community.
Assess resident's physical health and well-being
This task involves assessing the resident's physical health and well-being prior to discharge from the skilled nursing facility. It is important to ensure that the resident is medically stable and able to manage their care needs independently or with appropriate support. By conducting a thorough assessment, we can identify any potential risks or concerns and address them proactively.
1
Vital signs
2
Mobility assessment
3
Nutritional assessment
4
Skin assessment
5
Medication review
Review medication regimen
In this task, you will review the resident's medication regimen to ensure that it is accurate and appropriate for their needs post-discharge. This includes confirming the medications they are currently taking, checking for any potential interactions or contraindications, and making any necessary adjustments or recommendations. By reviewing the medication regimen, we can help ensure the resident's safety and optimize their medication management.
1
Confirm current medications
2
Check for interactions or contraindications
3
Make recommendations for adjustments
Consult with interdisciplinary team
This task involves consulting with the interdisciplinary team to gather input and collaborate on the resident's discharge plan. This includes healthcare professionals from various disciplines, such as nursing, therapy, social work, and pharmacy. By consulting with the interdisciplinary team, we can ensure that all aspects of the resident's care are considered and integrated into the discharge plan.
1
Nursing
2
Therapy
3
Social work
4
Pharmacy
5
Other
Planning appropriate discharge setting
In this task, you will plan the appropriate discharge setting for the resident based on their individual needs and preferences. This may include returning home, transitioning to an assisted living facility, or accessing other community-based resources. By identifying the most suitable discharge setting, we can support the resident's recovery and prevent unnecessary readmissions to the skilled nursing facility.
1
Returning home
2
Assisted living facility
3
Community-based resources
4
Other
Arrange home modifications if necessary
This task involves arranging any necessary home modifications to ensure that the resident's living environment is safe and supportive of their needs post-discharge. This may include installing grab bars, ramps, or other accessibility features. By making appropriate home modifications, we can help facilitate the resident's successful transition back into their home.
1
Grab bars
2
Ramps
3
Accessible bathroom modifications
4
Other
Organize required medical equipment for home use
In this task, you will organize the required medical equipment for the resident's use at home. This may include items such as a walker, wheelchair, or oxygen concentrator. By ensuring that the resident has the necessary medical equipment, we can support their safety and independence post-discharge.
1
Walker
2
Wheelchair
3
Oxygen concentrator
4
Other
Arrange home health services if needed
This task involves arranging any necessary home health services for the resident post-discharge. This may include nursing care, therapy services, or assistance with activities of daily living. By arranging appropriate home health services, we can provide the resident with the support they need to continue their recovery at home.
1
Nursing care
2
Therapy services
3
Assistance with activities of daily living
4
Other
Create a detailed care plan for discharge
In this task, you will create a detailed care plan for the resident's discharge from the skilled nursing facility. This includes outlining the specific care tasks, medications, and interventions that will be needed post-discharge. By creating a detailed care plan, we can ensure that the resident's care needs are clearly communicated and understood by all involved.
Discuss care plan with resident and family
This task involves discussing the care plan with the resident and their family to ensure their understanding and agreement. This includes explaining the care tasks, medications, and interventions that will be implemented post-discharge. By discussing the care plan, we can address any questions or concerns and ensure that the resident and their family are actively involved in the decision-making process.
1
Explain care tasks
2
Review medications
3
Address concerns or questions
4
Obtain consent for the care plan
5
Provide written instructions
Approval: Physician Review of Care Plan
Will be submitted for approval:
Create a detailed care plan for discharge
Will be submitted
Coordinate with social services for assistance if needed
This task involves coordinating with social services to explore available resources and support services that may be beneficial to the resident post-discharge. This includes assistance with financial resources, transportation, or social support networks. By coordinating with social services, we can help address any social determinants of health that may impact the resident's successful transition back into the community.
1
Financial resources
2
Transportation
3
Social support networks
4
Other
Schedule follow-up appointments
In this task, you will schedule the necessary follow-up appointments for the resident post-discharge. This may include appointments with primary care providers, specialists, or therapy services. By scheduling appropriate follow-up appointments, we can ensure that the resident's health and well-being continue to be monitored and any necessary interventions are implemented.
1
Primary care provider
2
Specialist
3
Therapy services
4
Other
Provide instructions for medication and care at home
This task involves providing the resident and their family with clear instructions for medication administration and care tasks to be performed at home. This includes explaining dosage instructions, potential side effects, and any necessary precautions. By providing clear instructions, we can support the resident and their family in effectively managing their care needs post-discharge.
1
Explain medication dosage instructions
2
Discuss potential side effects
3
Provide necessary precautions
4
Answer any questions or concerns
Train family members on resident's care needs
In this task, you will train the resident's family members on the care tasks and interventions that will be needed post-discharge. This includes demonstrating and explaining procedures, such as medication administration or wound care. By training family members, we can ensure that they are equipped with the knowledge and skills to provide appropriate support to the resident at home.
1
Demonstrate medication administration
2
Explain wound care procedures
3
Provide equipment training
4
Answer any questions or concerns
Verify insurance coverage for discharge plan
This task involves verifying the resident's insurance coverage to ensure that the proposed discharge plan is covered and financially viable. This includes checking for any restrictions, limitations, or pre-authorization requirements. By verifying insurance coverage, we can avoid any unexpected financial burdens or barriers to accessing necessary resources post-discharge.
1
Check for coverage restrictions
2
Confirm pre-authorization requirements
3
Identify any necessary co-pays or out-of-pocket costs
Review transportation needs for discharge
In this task, you will review the resident's transportation needs for their discharge from the skilled nursing facility. This includes ensuring that transportation arrangements are in place to safely and efficiently transport the resident to their chosen discharge setting. By addressing transportation needs, we can support the resident's successful transition back into the community.
1
Ambulance transport
2
Non-emergency medical transportation
3
Family or friend pickup
4
Other
Approval: Case Manager Review of Discharge Plan
Finalize and document discharge plan
This task involves finalizing and documenting the resident's discharge plan. This includes incorporating all relevant information, instructions, and agreements into a comprehensive discharge plan document. By finalizing and documenting the discharge plan, we can ensure that all stakeholders have a clear understanding of the plan and their respective roles and responsibilities.
Execute discharge plan on the date of discharge
In this task, you will execute the resident's discharge plan on the scheduled discharge date. This includes coordinating with all relevant parties, such as transportation services, home health providers, and family members, to ensure a smooth transition. By executing the discharge plan, we can facilitate the resident's successful return to their chosen discharge setting and promote continuity of care.
Confirmation of discharge plan execution
1
Successful transition to discharge setting
2
Identification of any issues or concerns
3
Need for post-discharge interventions or adjustments
