Page 86 - Business Development Orientation Binder

Applies to: VNSNY Certified Home Health Agency
Service: VNSNY Certified Home Health Agency
Procedure Section: Provider Service Administration
Number: CP.164
Page 2 of 5

2. During the course of care skilled professional communicates with the physician
regarding any revisions related to plans for the patient’s discharge.
3. The discharge plans should be communicated to the patient/ caregiver a
representative (if any), the physician(s) issuing orders for the home health plan of
care, or other health care professional who will be responsible for providing care
and services to the patient after discharge and such communication is
documented in the “Case Conference” coordination note.
4. Discharge Summary Coordination note is written at discharge.
5. Clinician coordinates or confirms discontinuation of all VNSNY Home Care
services. This includes all professional disciplines, paraprofessionals, laboratory,
durable medical equipment, and pharmacy.
6. If the physician does not concur with the discharge clinician consults with Branch
Director or designee for guidance.

B. If the agency determines that the patient's health care needs can no longer be met
safely at home the following must be done:
1. The clinician must inform the patient, patient representative (if any), and the
physician who is responsible for the patient’s home health plan of care that
agency cannot meet the patient’s needs without potentially adverse outcomes.
2. The agency should assist the patient and his or her representative (if any) in
choosing an alternative entity that may be able to meet the patient’s needs
based on the patient’s acuity.
3. Once the patient chooses an alternate entity, the agency must contact that entity
to facilitate a safe transfer and to ensure timely transfer of patient information to
facilitate continuity of care
4. The agency will continue to provide minimally essential home health services to
the extent necessary to address minimally essential patient health and safety
needs until an alternative placement becomes available or the patient or the
patient's legal representative, makes an informed choice to refuse such
placement. Clinicians must discuss the situation with their manager or regional
Branch Director or Vice President.

C. Patient /Family Refusal of Services
1. A patient who occasionally declines a service is distinguished from a patient who
refuses services altogether, or who habitually declines skilled care visits. In the
case of patient refusals of skilled services, clinicians should
a. Educate the patient on the risks and potential adverse outcomes from
refusing services

Responsibility: Quality Management Services-Homecare
Procedure date:
Revised: 6/2015, 12/2016, 12/2017, 12/2018
Approval: Senior Vice President Patient Care Service