Transfer and Discharge Policy


Patients shall be transferred or discharged from the Agency according to identified criteria and shall have a discharge summary written and filed in the patient’s medical record which is available to the physician upon request. The pertinent OASIS form will be completed at this time by the licensed professional initiating this change. 

The patient and will be an active participant, when possible, in planning for his / her transfer, referral or discharge from the agency.

The patient and / or their legal representative will be informed in a timely manner of impending transfer within a reasonable time frame prior to the actual event.

Patients will be informed of the alternative, if any to a transfer from the agency.

Patients in need of continuing care at the time of discharge will receive written and verbal instruction regarding any resources available to meet their needs.

Patients will be transferred to other agencies and care entities for the following:

1. If our Agency is unable to provide the necessary services the patient requires. The transfer is necessary for the patient’s welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities
2.If the patient’s insurance company refuses to allow our agency to provide services because we are not a preferred provider for the insurance company.
3.If the patient’s insurance changes to an HMO or PPO that refuses to allow our agency to continue to provide services to the patient.
4.The patient elects to be transferred.
5.The HHA determines that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired
6.The patient and his or her family is not compliant with the Plan of Care, thus creating an environment in which the agency is unable to provide services. 

The above criteria are the main reasons for referral to another agency, but are not the only reasons a patient will be referred to another agency. 

Criteria for Discharge: (not all inclusive)

1.The Plan of Care goal(s) are met.
2.The patient has needs which can no longer be met in the home and requires another level of care or referral to a different type of health care delivery system. The discharge is necessary for the patient’s welfare because the HHA  and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of  the patient exceed the HHA’s capabilities.
3.The patient or family refuses services and elects to be discharged.
4.The physician discontinues home health care.
5.The patient leaves the geographical area served by the agency.
6.The patient and his or her family are not compliant with the plan of care thus creating an environment in which the agency is unable to provide services.
7.There is no longer a source of reimbursement for Home Health Care. The patient must be given 2 days written and verbal notice that the agency is unable to provide services without a source of reimbursement. A Notice of Medicare Non-Coverage must be completed giving the patient the options available.
8.The patient no longer meets the criteria necessary for reimbursement.
9.The transfer or discharge is appropriate because the physician who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care have been achieved, and the HHA and the physician who is responsible for the home health plan of care agree that the patient no longer needs the HHA’s services;
10.The patient has expired.
11. The HHA ceased to operate.
12. The patient is admitted to post-acute facility such as in-patient rehab, transitional care or a skilled nursing facility.
13.The HHA determines that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. In cases where the patient is being discharged for cause the Agency will:

        a.Advise the patient, representative (if any), the physician(s) issuing orders for the home health plan of
           care, and the patient’s primary care practitioner or other health care professional who will be responsible
           for providing care and services to the patient after discharge from the HHA (if any) that a discharge for
           cause  is being considered;
        b.Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other
            persons in the patient’s home, or situation;
        c.Provide the patient and representative (if any), with contact information for other agencies or providers
            who may be able to provide care; and 
        d.Document the problems and efforts made to resolve the problem(s), and enter this documentation into
            its clinical records.