Discharge
Which discharge visit to use, the notice the patient is owed, and how to end an episode so the patient stays well.
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?
| Situation | Visit type |
|---|---|
| Discharging from the agency — all disciplines, including PT and OT | OASIS Discharge |
| Discharging from skilled nursing only, other disciplines continuing | RN Discharge with Discharge Summary |
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), generally delivered at least two days before care ends, which tells them how to request an expedited review.
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.
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.