Understanding the Patient Discharge Process

The discharge process for a homebound patient really begins during the first visit made by our Nurse. The Patient's Rights & Responsibilities, as stated by law, are explained by the Visiting Nurse and must be clearly understood by both patient and family. A complete assessment is done, including past and present medical history as well as a social environment status.

Working in conjunction with the physician, a plan of care is established. This may include skilled nursing, physical therapy, speech therapy, occupational therapy, home health aide services and a social worker. The patient and the family have an important role in creating this plan of care.

Safe home management is crucial. As the patient's condition improves, the nurse or therapist, and/or home health aide gradually decreases their visits. The patient is never discharged until he or she is competent in their self care, or a family member or significant other/friend has been instructed in a caregiver role. At the time of discharge, the patient is invited to complete an evaluation questionnaire, which is returned to VNSW and reviewed by the Director of Quality Improvement who then personally follows up on any comments or suggestions that have been made.