Discharge

Discharge planning starts at the start of care. The discharge visit is where that plan is delivered — and it is a clinical intervention in its own right, not a formality.

The last visit plotted should always be a discharge. See Plotting Visits.

Which discharge visit?

The OASIS discharge closes the episode and produces the outcome data the agency is measured on. The nursing-only discharge closes your discipline while the episode continues.

If therapy is still on service and nursing is finished, it is the second one. Getting this wrong either closes an episode that should stay open, or leaves one open that should have closed.

The deadline

The discharge assessment is completed within 2 calendar days of the discharge visit, or of learning that the patient has been discharged.

When to discharge

Any of these:

• Goals met. The patient can do what they needed to learn to do.
• No longer homebound. A success — document it plainly and discharge. See Homebound Status — What Actually Qualifies.
• No remaining skilled need. The care still needed can be safely provided by the patient, a caregiver, or an unskilled service.
• The patient declines further care. Their right. Document the refusal and what you told them about the risks.
• Moving out of the service area, or transferring to another agency.
• Transferred to hospice.

The conversation should not be a surprise. If the first time the patient hears about discharge is at the discharge visit, discharge planning did not happen.

Notice the patient is owed

When the agency ends covered services and the patient disagrees or may wish to appeal, they are entitled to advance written notice — a Notice of Medicare Non-Coverage (NOMNC), which tells them how to request an expedited review.

It is signed 48 hours before discharge. That is why discharge planning has to be a conversation the patient has already had, not news delivered on the last visit.

Where services are reduced or ended for reasons of coverage rather than clinical readiness, a Home Health Change of Care Notice (HHCCN) may also apply.

Know which your agency uses and when. Delivering these late, or not at all, is a common survey finding — and it removes a right the patient actually has. If you are unsure whether a notice is required, ask before the visit, not after.

If you realise late that the notice has not been delivered

This happens, and there is a right way through it. The notice is dated the day it is actually delivered to the patient — never an earlier date.

You have two legitimate options:

1. Deliver it now and move the discharge, so the patient still gets their 48 hours.
2. Deliver it now, date it today, and tell your Field Supervisor that the notice went out late. A late notice that is honestly dated is a problem the agency can manage.

Never date a notice earlier than the day the patient signed it. A patient-signed form carrying a date the patient did not sign on is a falsified record, and it converts a timing problem into something far more serious. See Corrections, Addenda, and Late Entries.

The way to stop needing this at all is on the other side of the episode: discharge planning starts at the start of care, so the last visit is never the first the patient has heard of it.

Which discharge, in practice

• OASIS discharge — the patient is leaving the agency. The last discipline still seeing the patient does it. If two disciplines discharge on the same day, whoever sees the patient last that day does it.
• RN discharge visit — nursing is discharging but PT, OT, or ST are staying on.

Do not submit the RN discharge from the discharge summary or the visit note as separate pages. Sign at the location where you have to pick either the discharge summary or the nurse note.

The discharge summary

Completed with both types of discharge — attached to the nursing-only discharge, and a separate part of the OASIS discharge. Fill in every blank.

The discharge order

A plot order is needed for both types of discharge.

Episode Manager → Order tab → Task dropdown → Physician Order → assign to clinician → select the discharge date on the calendar → Insert/Update Task.

Then write it:

1. Hot Box → the physician order for that patient → write the discharge order with the effective date and the reason — discharge patient from nursing services / from all Phoenix Home Care services effective [date] due to all goals met → sign
2. Or: Order tab → physician order → Details → View on the banner → Physician Order → write → sign

Goals at discharge

Every goal that can be met must be met, and a goal must be at 90% before it can be marked met — see Goals and Interventions in WellSky.

Uploading the NOMNC

Plot it first: Episode Manager → Misc tab → Task dropdown → NOMNC → assign to clinician → click the date → Insert/Update Task. It appears on the not-yet-done list.

Then upload, either way round:

1. Misc tab → Details on the NOMNC → View on the banner → NOMNC → Choose File (the filename shows in black) → Upload Attachment (it turns blue) → Complete
2. Or: Hot Box → the NOMNC listed under the patient → Choose File → Upload Attachment → Complete

The file link turning blue is how you know it actually attached. Black means it has not uploaded yet.

The discharge visit

Final assessment

Full assessment and the OASIS discharge. Score what you observe today — this is the data that will be compared against the SOC to measure whether the patient improved.

Make sure the patient can manage

Before you leave, the patient or caregiver should be able to demonstrate, not just describe:

• Their medications — what, when, and what each is for
• Any ongoing care they are continuing — dressing change, glucometer, weights
• Their warning signs, and what to do about each
• Who to call, for what, and the number to call

Teach-back, every item. The discharge visit is the last chance to find out that something never landed.

Written discharge instructions

Leave them in the house, where they will be found:

• Medication list
• Warning signs and what to do
• Follow-up appointments, with dates
• Equipment and supply contacts
• Physician contact details
• How to get back to us if things change

Close the loop

• Notify the physician the patient has been discharged, with a summary of the episode
• Notify the other disciplines
• Return or arrange collection of agency equipment
• Complete the discharge summary

Discharge against medical advice, or for cause

Patients may refuse further care, and occasionally an agency must discharge for cause — an unsafe environment, threats to staff, or a patient who repeatedly will not be home.

Either way: document what happened factually, what you explained about the risks, who was notified, and what alternatives were offered. Involve your Field Supervisor before the visit if you can. Discharge for cause has notice requirements and is not a decision a field clinician makes alone.

Where discharge goes wrong

• No discharge visit plotted. Discovered weeks later, and now the assessment window is long gone.
• The wrong discharge type, closing an episode that should have stayed open for therapy.
• The patient had no idea it was coming.
• Required notice not delivered, removing the patient's right to appeal.
• Teaching "completed" but never demonstrated. The first return visit is often the readmission.
• Discharged because the certification period ended, rather than because the patient was ready. Recert is a decision, not a default — see Recertification.

Related

• Transfer
• What Every Visit Note Must Prove