1. Rural stearns Live Well at Home coalition (SM)
Discharge Flow Chart
CentraCare Health Paynesville: Complete the Live Well at
Home Rapid Screen© upon admission. All Moderate to High
risk individuals are referred to the Support Planner.
Belgrade Block Nursing Program: Work directly with the
Support Planner in discharge planning; Support Planner will
complete all screenings including the Live Well at Home
Rapid Screen©.
The Support Planner will then meet with the individual prior
to discharge to complete:
 Introduction to The Rural Stearns Live Well at Home Coalition
 Program Registration, Intake and baseline assessments
 Offer Support Planning Services
 Offer Eat Well Get Well (10 free Home Delivered Meals)
 Offer Skilled Nursing (2 FREE in home assessments)
3-7 DAY IN HOME FOLLOW UP
The Support Planner will complete an
in home assessment within 3-7 days
following discharge:
Live Well at Home Rapid Screen©
Survey Questions
Benefits Screening
Safety Assessments
Medication Assessments
Nutritional assessments
Continued Services
Enroll in additional services
Referrals as needed
ONE MONTH & QUARTERLY IN
HOME FOLLOW UP
The Support planner will meet with the
individuals for a one month in home fol-
low up and quarterly thereafter.
Live Well at Home Rapid Screen©
Survey Questions
Safety Assessment
Medication Management
Nutrition Assessments
Continued Services
Enroll in additional services
The Support Planner will continue to
meet with each individual enrolled
on a quarterly basis until the individ-
ual graduates the program or
declines services.
Readmission rates will be complied
on a quarterly basis as well as a
Participant Satisfaction Survey to
measure how well individuals feel
they are doing living at home, how
confident they are in their ability to
remain living at home and how
satisfied they are with the services
they are receiving.