Nursing Home Social Services Reference/Flow of Care/Changes in Condition

Residents have changes in condition at times. These can be times when the resident has regained sufficient function to be able to care for themselves. This allows them to discharge from the nursing home into the community. For information about this process, see the discharge section: Nursing Home Social Services Reference/Flow of Care/Discharges and Transfers . Other changes in condition represent worsening physical or mental health that require the care of a hospital or psychiatric unit. The most frequent reason for hospital care is falls. Falls can cause TBIs, fractures, sprains and these can cause debilitation that lasts more than one day. For more information about falls, see https://www.cdc.gov/falls/data-research/facts-stats/index.html. Other reasons for nursing home residents to require hospitalization are infections, falls, cardiac issues, gastrointestinal issues. Exacerbations of current conditions such as COPD, diabetes, circulatory disease also contribute. For more details see: https://aspe.hhs.gov/reports/hospitalizations-nursing-home-residents-background-options-0 Change of condition reporting and notes are generally a nursing function but for mental health or behavioral issues social services may need to provide supporting information. This would be observations or behaviors reported to social services staff in the period up to and including the episode that precipitated the change in condition. Support for residents who have been sent to psychiatric units is optional but helpful in establishing trust and