MDS Alert

Published on Wed Jan 05, 2022 PDF

Question: What instructions are important to include for residents who are discharged to their community?

Arkansas Subscriber

Answer: Discharge instructions are unique to each respective resident, but the RAI Manual lays out the bare bones information of what any discharge should include. Remember that these instructions should be fully tailored to the individual resident!

The RAI Manual’s list includes:

• “The individual’s preferences and needs for care and supports;
  • personal identification and contact information, including Advance Directives;
  • provider contact information of primary care physician, pharmacy, and community care agency including personal care services (if applicable) etc.;
  • brief medical history;
  • current medications, treatments, therapies, and allergies;
  • arrangements for durable medical equipment;
  • arrangements for housing;
  • arrangements for transportation to follow-up appointments; and
  • contact information at the nursing home if a problem arises during discharge.”
• “A follow-up appointment with the designated primary care provider in the community and other specialists (as appropriate).”
• “Medication education.”

Although an individual resident’s situation may seem complicated, the RAI Manual reminds care team members (including those working on a resident’s interdisciplinary team) that successful discharge is possible in most situations, especially when the discharge plan is thorough and plumbs any available support.