Post-discharge plan of care means the discharge planning process, which includes assessing continuing care needs and developing a plan designed to ensure the individual’s needs will be met after discharge from the facility into the community.
Things to consider when reviewing discharge plans:
• Does the discharge summary have information pertinent to continuing care for the resident?
• Is there evidence of discharge planning in the records of discharged residents who had an anticipated discharge or those residents to be discharged shortly (e.g., the next 7-14 days)?
• Do discharge plans address necessary post-discharge care?
• Has the facility aided the resident and his/her family in locating and coordinating post-discharge services?
• What types of pre-discharge preparation and education has the facility provided the resident and his/her family?
Residents under a therapy plan of care are receiving all these services. In addition the therapy department is a vital part of the care team in assessing the residents needs at home, recommending any needed adaptive equipment, home health care, and family education. We can provide home assessments where the resident and therapists meet at their home and watch them perform all activities of daily living, assess entrance and exit of the home, and make needed modifications to ensure a safe transition home.
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