Set up follow-up care appointments or telehealth options
7
Advise the family on home healthcare regimen
8
Approval: Home Care Regimen
9
Prepare and submit insurance discharge paperwork
10
Arrange for patient transportation home
11
Inspect home for any needed modifications
12
Delivery and setup of necessary medical equipment at home
13
Ensure provision of necessary medical supplies at home
14
Train family on use of medical equipment
15
Approval: Medical Equipment Usage
16
Update patient's medical records
17
Discuss patient’s dietary requirements, if necessary
18
Arrange a home visit schedule with a home health nurse
19
Hand over patient to family or home caregiver
20
Perform final assessment on hospice discharge
Assess the patient's current condition
Assess the patient's current physical and emotional well-being to determine if they are stable and ready for discharge. Take note of any symptoms, pain levels, or concerns that need to be addressed before the patient leaves the facility. Ensure that the patient is comfortable and prepared for the transition to home care.
1
Review medication list
2
Check vital signs
3
Evaluate pain management
4
Assess emotional state
5
Discuss any specific patient concerns
Prepare complete documentation for discharge
Gather and organize all necessary paperwork and documentation for the patient's discharge. This includes medical records, insurance information, consent forms, and any special instructions or care plans. Ensure that all documents are accurate, complete, and ready for submission or distribution as needed.
1
Medical records
2
Insurance information
3
Consent forms
4
Care plans
5
Special instructions
Inform relevant medical team about discharge
Notify the appropriate medical team members about the patient's impending discharge. This includes doctors, nurses, and other healthcare professionals who have been involved in the patient's care. Provide them with an overview of the patient's current condition, any special instructions or care plans, and the expected date and time of discharge.
1
Doctor
2
Nurse
3
Social worker
4
Physical therapist
5
Occupational therapist
Prepare medical prescriptions for home use
Review the patient's medication list and prepare any necessary prescriptions for home use. Take into account any changes in medication or dosage that may be needed for the patient's continued care. Ensure that the prescriptions are accurate, legible, and include clear instructions for the patient and caregivers.
1
Pain medication
2
Antibiotics
3
Anti-anxiety medication
4
Medical supplies
Approval: Medical Prescription
Will be submitted for approval:
Prepare medical prescriptions for home use
Will be submitted
Set up follow-up care appointments or telehealth options
Schedule follow-up care appointments for the patient with relevant healthcare providers. This may include doctors, nurses, therapists, or other specialists who will continue to oversee the patient's care. If telehealth options are available, provide information on how to access and utilize these services for remote check-ins or consultations.
1
Doctor appointment
2
Physical therapy session
3
Nurse check-in
4
Telehealth instructions
Advise the family on home healthcare regimen
Educate and guide the patient's family members or primary caregivers on the home healthcare regimen. Provide instructions on medication administration, wound care, pain management, mobility assistance, or any other specific care tasks that need to be performed at home. Ensure that the family members are confident and capable of providing the necessary care.
Approval: Home Care Regimen
Will be submitted for approval:
Advise the family on home healthcare regimen
Will be submitted
Prepare and submit insurance discharge paperwork
Complete and submit all necessary insurance discharge paperwork on behalf of the patient. This may include claims, authorizations, or documentation required by the insurance provider to continue coverage or reimbursement for the patient's care. Ensure that all forms are accurate, signed, and properly filed according to the insurance company's requirements.
1
Claim forms
2
Authorization requests
3
Reimbursement documentation
4
Insurance contact information
Arrange for patient transportation home
Make necessary arrangements for the patient's transportation home. This may involve coordinating with a transportation service, arranging for a family member or caregiver to pick up the patient, or providing instructions on accessing public transportation if applicable. Ensure that the mode of transportation is safe, comfortable, and appropriate for the patient's needs.
1
Ambulance
2
Family member or caregiver
3
Public transportation
4
Medical transport service
Inspect home for any needed modifications
Conduct a thorough inspection of the patient's home to identify any modifications or adaptations that may be necessary to ensure a safe and accessible living environment. This may include installing grab bars, ramps, or other assistive devices, rearranging furniture, or addressing any hazards or obstacles that could pose a risk to the patient's safety.
1
Install grab bars
2
Rearrange furniture for accessibility
3
Address trip hazards
4
Install ramps
5
Secure loose rugs
Delivery and setup of necessary medical equipment at home
Coordinate the delivery and setup of any medical equipment or supplies that the patient will need at home. This may include items such as a hospital bed, wheelchair, oxygen concentrator, or mobility aids. Ensure that the equipment is in good working condition, properly installed, and that the patient and caregivers are trained on its use.
1
Hospital bed
2
Wheelchair
3
Oxygen concentrator
4
Mobility aids
5
Medical alert system
Ensure provision of necessary medical supplies at home
Ensure that the patient has an adequate supply of necessary medical equipment, medications, and supplies at home. This may include medications, wound care supplies, disposable gloves, catheters, or other items that are essential for the patient's care. Make arrangements for the delivery or procurement of these supplies as needed.
1
Medications
2
Wound care supplies
3
Disposable gloves
4
Catheters
5
Incontinence products
Train family on use of medical equipment
Provide training and guidance to the patient's family members or primary caregivers on the proper use and maintenance of any medical equipment that will be used at home. Ensure that they understand how to safely operate the equipment, troubleshoot common issues, and clean or disinfect the equipment as needed.
1
Hospital bed
2
Wheelchair
3
Oxygen concentrator
4
Mobility aids
5
Medical alert system
Approval: Medical Equipment Usage
Will be submitted for approval:
Train family on use of medical equipment
Will be submitted
Update patient's medical records
Update the patient's medical records to include any relevant information or changes as a result of the discharge process. This may include updating diagnoses, medication lists, care plans, or other documentation that will be necessary for the patient's ongoing care.
Discuss patient’s dietary requirements, if necessary
Engage in a conversation with the patient or their family members to determine any specific dietary requirements or restrictions that need to be considered for their care at home. Ensure that the patient's nutritional needs are understood and that appropriate recommendations or referrals are provided to support their dietary requirements.
Arrange a home visit schedule with a home health nurse
Coordinate a schedule for home visits with a home health nurse who will provide ongoing care and support to the patient. Collaborate with the nurse to identify the frequency and duration of the visits, as well as any specific goals or areas of focus for the patient's care. Ensure that the schedule is communicated to the patient and caregivers, and that any necessary adjustments can be made as needed.
Hand over patient to family or home caregiver
Facilitate a smooth transition of care by formally handing over the patient to their family members or designated home caregiver. Provide a comprehensive overview of the patient's condition, care plan, medication instructions, and any necessary contact information for follow-up or emergencies. Ensure that the family members or caregiver feel confident and prepared to assume responsibility for the patient's ongoing care.
Perform final assessment on hospice discharge
Conduct a final assessment to ensure that all necessary tasks and preparations have been completed for the patient's discharge. Review the checklist items, documentation, and any outstanding or unresolved issues to confirm that everything is in order. Seek feedback from the patient, family members, or caregivers to ensure their satisfaction and address any remaining concerns or questions.
