O-13-104 Discharge Follow-Up

👤 RESPONSIBLE POSITION  |  ROLE

Clinical Supervisor or Designee

🎯 PURPOSE

To outline the process for identifying and following up with clients after discharged from the agency.

A client’s status may decline or need further follow up after discharged from home care services that can be identified in order to prevent them from rehospitalization or further decline.

🔄 PROCESS

1. Discharge Planning Assessment: At the discharge visit, the clinician identifies that the client requires follow up due to needs for further support or concerns of potential decline after home care services has ended (refer to O-12-950 Discharge Planning Assessment Tipsheet for additional information).

   1. The clinician answers “yes” to the following question:

      

2. Identify Clients for Discharge Follow-Up: The Clinical Supervisor/designee will receive an Administrative Task to complete “Discharge Follow-Up” weekly.
   • Refer to O-14-311 Process Discharge Follow-Up Administrative Task.
3. Initiate Follow-Up Phone Call: Clinical Supervisor/designee will call the client around two weeks post discharge date or as indicated per discussion with clinician.
   • Inquire the client’s status to identify if they are declining or are need of additional support. If this is identified, options for follow up include:
     • Obtain an order from the client’s primary physician to resume home care services.
     • Provide further education on areas need support, if required.
     • Case Conference on recommended next steps.
4. Clinical Documentation in Medical Record: Clinical Supervisor/designee will complete the following:

   1. Document follow-up in coordination note: FOLLOW-UP CALL TO DC CLIENT:

      

   2. Coordinate further services or follow up, if required.

📅 Effective: 04.30.2025  | 🛠️ Revised: 10.23.2026  |  ✅ Approved: JM