POSSIBLE CRITERIA FOR HOME HEALTH DISCHARGES

Home Health Agency /Physician Initiated Discharges:

  • The Plan of Care goal(s) are met: The transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care have been achieved, and the HHA and the physician who is responsible for the home health plan of care agree that the patient no longer needs the HHA’s services;
  • The physician discontinues home health care.
  • The patient no longer meets the criteria necessary for reimbursement.
  • There is no longer a source of reimbursement for Home Health Care. The patient must be given 2 days’ written and verbal notice that the agency is unable to provide services without a source of reimbursement.                                                                                                          A Notice of Medicare Non-Coverage must be completed giving the patient the options available.
  • The patient has needs that can no longer be met in the home and requires another level of care or referral to a different type of health care delivery system. The discharge is necessary for the patient’s welfare because Caring Like Family and the physician who is responsible for the home health plan of care agree that our agency can no longer meet the patient’s needs, based on the patient’s acuity.  Therefore, Caring Like Family must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities.
  • The patient is admitted to a post-acute facility such as in-patient rehab, transitional care, or a skilled nursing facility.
  • The patient and his or her family are not compliant with the plan of care thus creating an environment in which the agency is unable to provide services.
  • The patient leaves the geographical area served by the agency.
  • The Home Health Agency ceases to operate.

Patient Initiated Discharge

  • The patient or family refuses services and elects to be discharged.
  • The patient has expired.

Discharge for Cause

  • The HHA determines that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. In cases where the patient is being discharged for cause the Agency will:
  1. Advise the patient, representative (if any), the physician(s) issuing orders for the home health plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered;
  2.  Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or the situation;
  3. Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and
  4. Document the problems and efforts made to resolve the problem(s), and enter this documentation into its clinical records.