Nursing Home Social Services Reference/Flow of Care/Discharges and Transfers

Discharges and Transfers There are several kinds of discharges both voluntary / by choice and involuntary. Voluntary discharges can be happy events of a resident who has found resources to maintain their life without the support of the nursing home. This includes transition cases that transfer to the community, rehab stays that are complete, residents that return home from respite care and those who have a breakthrough in their health with medications and/or wellness that allows them to go home or find a home in the community. Another kind of discharge is a transfer to another facility. This can be another nursing home or to a higher level of care such as an assisted living facility. This could be in the area, or a long distance transfer to place resident closer to friends or family. Long distance discharges require special considerations and arrangements. These will be discussed in a separate section below. Temporary transfers will require a 30 day hold on the resident's room. The basic elements of a discharge are: Medication list Doctor's discharge summary including diagnoses (Dxs) progress and plan including any change and/or follow-on orders Facesheet from facility with insurance information, dxs, emergency contact(s), family / friends, POAs, previous addresses, current phone number(s), demographic information including age, gender. Contact information for the nursing home medical records These papers/notes are typically organized by the Social Services person, printed for the resident and provided at the time of the physical discharge to the resident or representative. Additional copies generally have a per page copying cost. Plans for Voluntary Discharge Transfers A transfer to another facility can be requested by a resident. This is their right under CMS regulations and other general rights of citizens of our various communities. [citation] Steps for this kind of discharge are: Compilation of a discharge package for the referral, review and acceptance by receiving facility Faxing or secure emailing of this review package to the receiving facility Verification of the acceptance by the desired facility Coordination of billing and benefits to be sure that each facility gets paid for the resident while they are present and cared for at each facility. It is also necessary to be sure that lower level of care will be paid by Medicaid waivers for the receiving assisted care facility. Residential Hospice transfers can be assumed to be paid. Update discharge package to be sent with resident Coordinate admission to new facility and discharge to new facility including: unused medications and those that need to be ordered assistive devices owned by resident and those provided by receiving facility packing and preparing resident belongings for transport time that receiving facility will be ready for resident transportation for resident and belongings from current to new facility escort by a CNA if required completion paperwork to close chart Transition Program Many places in the country have programs to move Medicaid clients who can survive in the community with home healthcare. These transitions may be to an individual apartment, an shared apartment or another kind of community housing options. The team that does this transition work does most of the case management work for the resident. Applications for Section 8 or 811, applications for Home and Community Based Services (HBCS) and obtaining state IDs, social security cards and other details that are required to complete a transition. Coordination with this transition team is sometimes required, especially if the Social Services department holds some documentation, IDs or other required paperwork. Rehabilitation Completion / Wellness Discharge When rehab completes successfully, discharge from the rehab program to home is indicated. This discharge needs to be carefully planned for those who have Medicare and not Medicaid. Planning for these clients should start at admission and communication with the resident about the limits and conditions of Medicare LTC coverage is important for the safety and mental well-being of the resident. If this planning is not done well, residents could end up with a large bill to pay to the facility. For residents with Medicaid and Medicare, when Medicare funding ends and there is a return to Medicaid Long Term Care (LTC) continuing the stay at the nursing home with a lower level of skilled care. Medicaid generally requires a stay for at least a month (30 days) or Medicaid will not pay. These charges will then become the responsibility of the resident. Typically these residents cannot pay these kinds of charges and this almost always results in a loss for the facility. Involuntary Discharge Discharges that are ordered by the facility or other authorities but are not desired by the resident we will call involuntary discharges. These can happen for several reasons: Financial issues Behavior / criminal issues Care issues Plans for Involuntary Discharge Financial Issues These discharges are an exception to the safe discharge rules. A discharge for a non-paying, uninsured resident will be abrupt and will lack care arrangements. Discharge to the homeless shelter, charity center, community social services agency may occur in the best of circumstances. Clients who leave this way may or may not get medications given to them. Their belongings must leave with them in most cases and a return for visitation of residents is often allowed. Generally, those who leave for financial reasons must repay the debt before being re-admitted. Most facilities do not have a sunset term for this loss and the ban of residents from admission is for life. Details are generally subject to the policy of the facility or owning organization. Behavior / Criminal issues Residents at times exhibit behaviors that are difficult to manage by facility staff. These can be aggressive or annoying as listed below: Violence Sexual Harassment Stealing / Misappropriation Bullying or Harassment Unsafe Activities Breaking of Rules of Conduct Responses to some of these issues may include community police involvement. As a receiver of federal funds, the nursing home is obligated to follow procedures for responding to these situations. Lasting solutions to these issues with a resident may include a temporary or permanent transfer to a correctional or psychiatric facility or a permanent transfer to a nursing home with special facilities or programs for behavioral issues. [citation] Temporary transfers presume a 30 day hold on the resident's room. Care Issues There are times when the care staff can no longer medically serve a resident. This can be a temporary issue or a permanent one. Hospitalization for temporary acute issues such as pneumonia requiring breathing assist, deep pressure or other wounds, heart or circulatory issues requiring constant supervision can happen. More permanent issues such as late stage cancer and systemic disease in its last phases may not be handled well in the nursing home setting. The higher level of care from a nursing home is the hospital or ICU. Hospitalization is the usual response to this need. Most hospital transfers are considered temporary and presume a 30 day hold on the resident's room to allow the resident to return. Permanent Discharges to a Different County Medicaid is generally administered by counties despite the State and Federal administrative agencies. This may require a transfer of the resident's Medicaid benefits. Counties from time to time agree to continue to pay for a resident in the new county. Typically this will not be the case. Contacting the new county Medicaid office for the proper procedures will be necessary. This might include reapplying for Medicaid in the new county at most or a letter between counties at the minimum. Long Distance Discharge Considerations A complicated resident request is to be placed in another nursing home close or closer to family and friends. Of the steps of a discharge that are complicated, the most difficult is transportation of the resident and belongings to the new facility. This can be especially difficult for residents that are mobility challenged or require continuous oxygen supplementation. There are transport providers for these medically assisted transfers. They are expensive and will not be paid by Medicaid or Medicare. Vans, capable of transporting residents in power chairs or wheelchairs, can be rented. Family or friends will be the drivers of these vehicles. Arrangements for oxygen refills and care stops along the way need to be planned. Social Services workers may be asked to help with this. Use the advice and counsel of your administrator on this process. Also be prepared to help residents understand the difficulty and delay that are likely. Celestial Discharge "Celestial discharge" is a euphemism for discharge due to the death of the resident. This requires several steps and is similar to any other discharge in some ways. Collecting records and placing them in the medical archives is usually done by medical records staff. In this age of electronics this may be fairly simple and managed by the EHR for those electronic items. Residents and social services staff may have papers, identity cards, recent purchases and belongings that need to be distributed to surviving family, shredded or disposed of. Most facilities have a way to accept and distribute belongings that family does not want. Other residents or community donation centers are the usual target of such things. Social Services staff or other facility staff should not acquire these things unless there is some written will or documentation of such a gift. These kinds of gifts might well be discouraged to avoid conflicts of interest and disruption of the team spirit at the facility.