Answer»
- Referrals to community resources - must demonstrate knowledge of most common resources, i.e. home health, medical equipment, TITLE 19, Meals-on-Wheels, mental health services.
- Discharge planning starts with the pre-admission process
- COMPREHENSIVE documentation of all activities RELATED to discharge planning, including name and time of any phone CALLS, meetings or interactions.
- Communication with interdisciplinary team, resident and family
- Coordination of home health and equipment to coincide on day of discharge or earlier if training is NECESSARY on a new piece of equipment, i.e. 4-wheeled walker, glucometer, etc.
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