You’ve just arrived at work. It’s a typical Tuesday, but half-an-hour into your morning you find out that one of your residents has decided she wants to be discharged back to the community today.
What do you do?
- Nothing, it isn’t part of your job to assist residents with referrals or services to outside the facility.
- Decline to create a discharge plan since the resident requested it, not the physician.
- Follow up with the resident to arrange a safe, organized discharge within a reasonable time frame.
If you said number 3, then you are spot on. Regulation F745 is at play in this situation and this baby is all about the provision of medically-related social services. It states that the facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychological well-being of each resident.
That does sound a little overwhelming as a concept, but the intent of F745 is for facilities to provide each of their residents with sufficient and appropriate social services to meet their needs. Most of the burden of this does seem to fall on the social services, but understanding what the regulation mandates helps reduce stress in your day–to-day job and leads to greater job satisfaction.
So what are you expected to do in the Discharge Planning process according to F745?
- Advocate for your residents. Assist them in the assertion of their rights in the facility in accordance with:
- 483,10, Resident Rights
- 483.15, Transitions of Care
- 483.20, and §483.21, Comprehensive Person-Centered Care Planning
- Help keep your residents, their family and/or their representatives informed and educated about their health care options and the ramifications
- Make referrals and obtain the services they need from outside entities
- Assist residents with legal and financial matters
- Arrange transitions of care services
- Identify and seek ways of supporting your residents’ individual needs through the assessment and care planning process
Once all that is covered, then you have met the standards required and have offered your residents the best quality of care.
This framework comes from understanding the requirements of F745. It shows you what is expected in the area of discharge planning so next time you are met with a situation like the one above, you know what to do. Not only does it clearly lay out what is mandated, but also the area that licensing will review to assess compliance.