Home Care transfer to Nursing Home

Transfer of Care

A Home Care Agency and a Nursing Home

CASE #1

The following scenario is based on a U.S. setting but can be generalized. Just substitute for OASIS and MDS the relevant assessments done on discharge from home care and admission to nursing home.

A person receives home care services for a specified time. The discharge plan completed by the home care agency for this person specifies that when home care services are completed that she will be discharged from home care and admitted to a nursing home. On discharge from home care, the home care agency completes an OASIS discharge assessment. This assessment contains the following functional status information:

sensory status

integumentary status

respiratory status

elimination status

neuro/emotional status

ADL/IADL

patient management of medications and equipment

The home care agency encodes the functional status information (along with other information on the patient) into a CCD. This CCD is sent to the nursing home. The nursing home uses the functional status content of CCD to initially populate the MDS functional assessment sections. This data is available to be viewed by staff at the nursing home.

Use Case - fall prevention: On discharge from home care it is recorded on the OASIS discharge assessment that a patient needs a cane or walker to ambulate. On admission to the nursing home the staff know (from CCD passed to them from the home care agency) that a cane or walker must be available for this patient and that they can take any additional fall prevention measures.

CASE #2

Mrs. H is an 85 year woman whose 88 yr old husband has just died. Her daughter is temporarily living with her and has called the case manager for an urgent assessment review.. Mrs H and her husband were receiving home making and home health aide services from the agency and were monitored by the case worker over several years. Mrs. H has moderate cognitive impairment. She has showed a gradual decline in cognitive status and communication over several years. There has been no acute change. Her vision has deteriorated and she has been bumping into objects which may have contributed to her 2 falls in the past month. During the interview, Mrs H appears anxious, keeps repeating concerns about the next meal and checking that her daughter not leave her. The case manager notes the presence of these indicators of depression and includes a note to the nursing home to continue to assess for depression based on the recent life stressing loss of her husband and the new onset of mood indicators. The high fall risk will also be signaled to the nursing home with a potential suggestion for evaluating the underlying reasons for the fall risk including vision or physical changes. In addition, the nursing home will receive a detailed listing of her performance in each ADl task and the type of assistance needed eg set up help, supervision and cuing or physical assistance. Mrs. H has recently decreased her activity level. Her husband used to walk around the block with her regularly. She enjoyed walking with him and it seemed to calm her. She is independent on stairs but is easily disoriented and prone to wandering if left alone.