title = "Discharge Planning and Transition from Home Health"

content = """
Discharge from home health is not simply the cessation of visits — it is a planned transition that
ensures the patient can safely maintain their health status without skilled services, or that the
appropriate next level of care is arranged. Poor discharge planning contributes to avoidable
rehospitalization and patient deterioration.

**When Is a Patient Ready for Discharge?**
A patient is discharged from home health when one of the following conditions is met:
1. *Goal achievement:* The patient has met the functional and clinical goals defined in the care plan
   and can safely self-manage or continue with outpatient services.
2. *Plateau:* The patient has reached maximum rehabilitation potential and further skilled intervention
   is not expected to produce meaningful clinical improvement.
3. *Patient request:* The patient exercises their right to decline further services.
4. *Homebound status no longer met:* The patient's functional status has improved to the point that
   leaving home no longer requires considerable and taxing effort.
5. *Transfer to higher level of care:* The patient requires inpatient hospitalization, SNF, or hospice.

**Discharge Planning Process**
Begin discharge planning at start of care — not in the last week of the episode. At each recertification,
assess whether the patient is on a trajectory toward discharge and what resources will be needed:
- Outpatient therapy referrals (if continued skilled treatment is warranted without homebound status)
- Durable medical equipment that remains in the home
- Community support services (Meals on Wheels, senior centers, adult day programs)
- Medication management support (pharmacy blister packs, medication reminder services)
- Caregiver training completion (ensure the informal caregiver can safely support the patient)

**Discharge Documentation**
The clinical team completes a discharge OASIS, a discharge summary note, and a patient discharge
summary document. The discharge summary is shared with the referring and attending physician and
communicated to the patient and family. The coordinator ensures all documents are signed and
filed within required timeframes.

**Post-Discharge Follow-Up**
Within 72 hours of discharge, conduct a follow-up phone call to confirm the patient is stable,
that community resources have been activated, and that no new clinical concerns have emerged.
Document the call in the closed episode record. If concerns are identified during the call,
consult the clinical supervisor about whether the episode should be reopened.

**Avoiding Premature Discharge**
Discharging a patient before goals are met — to free up caseload or in response to family pressure —
is a patient safety risk and a potential compliance issue. All discharges must be clinically justified
and documented in the record. If a physician requests continued services, follow their guidance.
"""

version = "0.0.1"
