Resumption of Care (ROC) — Home Health Training

A resumption of care is what you do when a patient comes home after an inpatient stay and remains on service. Clinically it is the most dangerous moment in the episode: the medications have changed, nobody has explained the changes, and the patient is weaker than when they left.

What triggers a ROC

An inpatient admission of 24 hours or longer, for reasons other than diagnostic testing, where the patient returns home and stays on service.

That includes a hospital, a rehab facility, a skilled nursing facility, or a psychiatric unit. It does not include an emergency department visit the patient was discharged from the same day, and it does not include an overnight stay purely for a test.

If the patient does not come back to us, that is a transfer with discharge rather than a ROC — see Transfer.

The deadline

The ROC assessment must be completed within 2 calendar days of the patient's return home, or within 2 calendar days of the agency learning of the return — whichever is later.

"Learning of the return" is doing real work in that sentence, and it is also where agencies get caught. Hospitals do not reliably tell us. Build the habit of calling the patient when a visit is missed rather than assuming they went out.

Before you go

Get the discharge summary and the discharge medication list
Find out what actually happened — the admitting diagnosis is often not the story
Note any new equipment, new wounds, or new devices
Check whether new orders are needed before you can do anything
Check whether the reason for admission changes the plan of care entirely

In the home

Medication reconciliation is the visit

This is the single highest-value thing you do at a ROC, and it should be the first thing you do.

Get every bottle in the house on the table — including the ones from before the admission
Compare against the discharge list, item by item
Look specifically for: medications stopped in hospital that the patient has restarted at home; doses changed that the patient has not noticed; duplicate therapy under brand and generic names; anticoagulants started or changed
Ask what they have actually taken since getting home

Discrepancies here are extremely common and are exactly what readmits the patient. Every discrepancy goes to the physician the same day — see Verbal Orders and Clarifications.

Full reassessment

The patient is not the patient you knew two weeks ago. Reassess from scratch:

Vital signs including pulse oximetry
Functional status — expect decline, and score what you observe
New or changed wounds
Cognition and mood
Caregiver capacity, which may have changed while they were managing the hospital stay

Re-establish homebound status

Do not carry forward what was written before the admission. The reasons may be stronger now, and they need to reflect today's patient.

Rebuild the plan of care

Does the frequency still fit? Usually it needs to increase — front-load after an inpatient stay
Are the goals still the right goals?
Do other disciplines need to be added? A patient who fell and fractured a hip needs PT and probably OT
Are the physician notification parameters still right?

Teach for the readmission risk

Before you leave, the patient or caregiver should be able to say:

What changed about their medications, and why
What signs mean call us
What signs mean call 911
When we are coming back

After the visit

Complete the OASIS ROC within 2 days of the return home or of learning of it
Get the updated plan of care to the physician for signature
Tell the scheduler about the frequency change the same day
Notify the other disciplines on the case

Where ROC goes wrong

Nobody knew the patient was home. The visit was marked missed, and the two-day clock ran out. Call before you assume.
The old plan of care is carried forward unchanged. The frequency that was right before the admission is almost never right after it.
Medications reconciled against the discharge list only. The list is what the hospital intended, not what is in the kitchen.
Homebound language copied from the SOC. Reviewers notice identical text across months.