Page 11 - Home Health Marketing

o Make efforts to resolve the problem(s) presented by your behavior or the
behavior of other persons in your home or situation;
o Provide you and your representative, if any, with contact information for
other agencies or providers who may be able to provide your care; and
o Document in your medical record the problem(s) and efforts made to
resolve the problem(s).
 Your death occurs while you are receiving home health services.
Discharge planning will begin when you are admitted to the agency based on
the findings of the comprehensive assessment performed at admission. You
and/or your representative will receive education and training to facilitate a
timely discharge. Any revisions related to plans for your discharge will be
communicated to you, your representative, your caregiver, all physicians
issuing orders for our agency plan of care, your primary care practitioner and
any other health care professionals who will be providing care and services to
you after discharge from our agency.

You will be given advance notice of your discharge or transfer to another
agency in accordance with applicable state regulations, except in the case of
an emergency. All discharges or transfers will be documented in your medical
record. When a discharge occurs, an assessment will be done. You will receive
an updated list of your current medications along with any instructions
needed for ongoing care or treatment. We will coordinate referrals to available
community resources as needed.
If you transfer from this agency to another home health agency, skilled
nursing facility, inpatient rehabilitation facility or long-term-care hospital, we
will assist you and your caregivers in selecting the facility that best meets
your needs by using and sharing information that includes, but is not limited
to, data on quality measures and resource use measures that is relevant and
applicable to your care goals and treatment preferences.

Following your discharge or transfer, we will send a discharge or transfer
summary within the timeframes specified by federal regulations to your
primary care practitioner, other health care professional and/or facility who
will be providing care and services to you after discharge or transfer from our
agency. The summary will include all necessary medical information
pertaining to your illness and current course of treatment, post-discharge
care goals and treatment preferences. We will comply with requests for
additional clinical information as may be necessary for your treatment by the
receiving facility or health care practitioner.
If you elected to transfer from another agency and were under an established
plan of care, Medicare requires us to coordinate the transfer. The initial home
health agency will no longer receive Medicare payment on your behalf and
will no longer provide you with Medicare covered services after the date of
your elected transfer to our agency.

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