Here's a practical guide for nurses in helping patients make a transition from one care setting to another. Focuses on DRGs and the critical need for planning and teamwork resulting from early discharge. Provides checklist to help ensure continuity of care, as it relates to health promotion, recuperation, short- and long-term rehabilitation, chronic disease, institutional care, and terminal illness. Also includes legal and ethical considerations.

Book discusses federal regulations surrounding discharge planning.

Discharge Planning for Home Health Care is a comprehensive, step-by-step guide to assessing the needs of patients and establishing a coordinated hospital-to-home discharge plan. The referral format and assessment tools provide the user with an organized and systematic approach for the transition of the patient through the continuum of care. This comprehensive resource is based on current reimbursement and regulatory issues and contains over 150 tools for easy application to a broad spectrum of health care settings.

Designed as a text or self-learning manual, this book offers nurses practical programs for discharge planning for the elderly. This program was developed by the Education Development Center and Boston's Beth Israel Hospital. The premise of the book is that nurses should be involved in the discharge planning process, along with other members of the health care team, from the first day of hospitalization. Topics include assessing the patient's physical, mental, and functional needs; assessing the caregiver and home environment; matching patient needs with appropriate resources in the community or institutional setting; patient advocacy; and ethics. Each chapter includes learning objectives, case studies, and clinical exercises. In addition, the many sample forms, charts, and diagrams help to clarify complex information.