Discharge Planning
The Process at Hillsdale
Community Health Center
Mission Statement
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Hillsdale Community Health Center is an
independent, not- for- profit community
hospital dedicated to EXCELLENCE.
Vision Statement
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Guided by our mission, each one of us is
fully committed to exceed customer
expectations by providing comfort and
continuing improvement in healthcare in an
efficient, courteous manner to all.
Discharge Planning
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Meeting the patient’s continuing healthcare
needs after discharge.
Necessitate the admission to the hospital or
May occur as an expected outcome to
medical and/or surgical intervention.
Identify a patient’s uniqueness for:
physical, physiological, social and spiritual
needs.
Discharge Planning
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Begins on the day of admission
Physicians and therapists also assess their
patients
Discharge Planning staff also review
patient charts daily for patients with a
potential need for assistance.
Agencies/Resources
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Long-term care
Short-term care
Home Health
Hospice
Sub-acute care
Rehabilitation
Support Groups
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Durable medical
equipment
Adult Foster Care
Mental Health
Community Agencies
Wound Care
I.V. Therapy
‘Automatic’ high risk Adult Referral
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Homeless
Home Intravenous
therapy
Suspected Abuse
New diagnosis CVA
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Hip/Knee
replacements
Fractures
Trauma victims
Psychosocial
concerns or crisis
intervention needs
Pediatric ‘High Risk’ Referrals
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Trauma victims
Femur fractures
requiring specialized
cast application
Suspected abuse
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Home intravenous
therapy
Anticipated long-term
school absence
Referral Screening Criteria: The
following are considered in addition to
diagnosis
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Age 65, lives alone
Inadequate or no known
social support system
History of readmission
within 30-60 days
Readmission within 15
days
Transfer from another
facility
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Suspected
abuse/neglect/failure to
thrive
Chemical/substance
abuse
Changes in body image
(colostomy, etc)
Terminal condition
Attempted suicide
Referral Screening cont:
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Apparent inability of patient/family to
follow the treatment plan
Inability of patient to return home in view
of feelings expressed by family
Inability of family to respond to normal
guidance in preparing to cope with the
patient’s dependency, disability or behavior
resulting from the illness or injury.
Department Referral
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The Discharge Planning department has an open referral
policy for all patients. A referral can be made by anyone
with concern for the patient.
A referral can be a physician order or initiated by the
Discharge Planning department without an order.
The Discharge Planner will meet with the patient/family
within one business day of the referral (excluding w/e &
holidays).
Documentation of the Discharge Plan will be found in the
Progress notes so that all medical team members are
aware of the Plan.
Adult Protective Services
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An adult has the “right” to live anyway they
choose as long as they are oriented and
competent. If the patient is not oriented and
determined incompetent, and does not have a
POA or guardian, then an APS referral needs to
be made.
Who determines competency? A Neurologist,
Psychiatrist, or Phd Psychologist
Adult Protective Services
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Other times a referral might be made (if they are
not alert/oriented):
If patient does have POA or guardian and they
have been neglected or abused.
If the patient does not have any POA or guardian
and they require medical attention.
If patient has been abandoned
(See Attached HCHC Policy)
Child Protective Services
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Most often referral is through the ER
Complete documentation on a 3200 Form
(See attached) and call Hotline (See
attached policy)
Original 3200 is mailed to DSS and copy
maintained in our office
Child Protective Services
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Times a referral might be made:
Once a child is admitted in the hospital if parents are
neglectful, abusive, or physical with the child
A NB whose mother/father is neglectful, abusive, or
physical
A NB whose mother/father has low IQ ability to
adequately care for child (documented & confirmed by
family/friends)
If child confesses any type of apparent neglect/abuse
Disagreement of adoption status between mother & father
Skilled Nursing Facility
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Placement occurs after a 3 day hospital stay (so
Medicare will cover first 20 days at 100%)
Patient needs a ‘skill’ such as: therapy, nursing
care (IV therapy, wound care)
Medicare does not pay for ‘custodial’ care (Pt
needs assistance with ADL’s and has no skill)
Two required forms need completed for
admission; one signed by physician (mental
illness screening)
Home Care Referral
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Patient must be homebound
Patient must have a ‘skill’: therapy, nursing
care (wounds, IV therapy, diabetic
management, etc).
Home Care is a good transition after a SNF
stay
Mental Illness & Substance Abuse
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The mentally ill
patient has the option
of voluntarily seeking
treatment programs,
either in-patient or as
an out-patient.
Sometimes this
decision is made on
an involuntary basis.
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Those who have a history
of substance abuse
actively chose if they
would like to attend
treatment
facilities/programs.
Substance Abuse
programs are self
referrals by the patient.
The patient is given a list
of programs by the
Discharge Planner.
Questions, Comments……..
Thank you for attending!