The document provides instructions for nurses on discharging patients and addressing their needs after leaving the hospital. It discusses arranging for home health services, placement at a skilled nursing facility, durable medical equipment, and medications. The key steps are determining the patient's insurance, choosing providers, notifying the chosen providers, and sending relevant patient information and orders.

1. Patient Discharges
Home Health
Skilled Nursing
DME
Meds

2. What Do I Do If The Social Worker Is Not Here?
Nurses do many things to provide care for their patients while
they are in the hospital.
But what happens when it is time for the patient to go home?
Simple – see the case manager or social worker. Unless it’s a
weekend.
Then what do I do?

3. Assess the Patient’s Needs
Does my patient need Home Health?
Do they need DME?
Can they go home with just their family to assist them?

4. Home Health
If the patient will need home health services the first
thing the nurse needs to know is which insurance they
have. This information can be found on the patient’s
face sheet in the chart.
Each home health agency provides a list of insurances
they contract with. A binder has been placed at the
main nurses station with these lists.

5. Home Health
After determining which home health agencies to use,
the nurse should offer the choices to the patient and
have a patient choice form signed.
The next step is to call The final step is
the home health fax the patient’s
agency to notify them information;
that they have a new face sheet, H&P,
patient. and orders.

6. Skilled Nursing Facility

7. Skilled Nursing Facility
There are several facilities locally:
St. George Care and Rehab
Red Cliffs Regional Rehab
Kolob (In St. George and Cedar City)
Coral Desert Rehab
Highland Manor in Mesquite
Acute Rehab

8. Skilled Nursing Facility
The nurse should provide a list of the available facilities
to the patient and allow them to chose. Again, a
patient choice form needs to be signed.
A call should be made to the facility to notify them of
the patient’s choice.

9. Skilled Nursing Facility
Then a copy of the face sheet, the H&P, a
medication list, and copies of the therapy notes
are faxed to the facility, along with the orders.
(Make it easy for the doctor – print a medication
transfer list for him or her.)
A S.N.F. packet should be filled out and placed in
the chart for the doctor to fill out, along with a
P.A.S.S.R. packet.
Don’t forget – a hard copy script for any narcotics
must accompany the patient.

10. D.M.E.
D.M.E., or Durable
Medical Equipment
Includes such things F.Y.I.
as: Front Wheel Bedside commodes
Walkers, and shower chairs
Wheelchairs, Beds, are not covered by
and Oxygen Medicare.
Don’t forget that
The process to when ordering
arrange D.M.E. is the Oxygen you must
same as for Home include the patient’s
Health. O2 sats on room air
with the order.

11. Medications
There are medications
which require pre-
authorization from the
patient’s insurance. One
is Lovenox, the other is
oral Zyvox.

12. Medications
If these medications have not
already been pre-authorized,
the easiest way to do it on the
weekend is to go thru the
patient’s pharmacy. First
check for the availability of
the medication at their
pharmacy, as not all
pharmacies carry these meds.

13. Medications
Call in the script to the pharmacist, and ask them to give
you the cost to the patient.
Walgreens and Harmons generally have any
medications, but you can always start with the
patient’s own pharmacy.

14. Ready For Discharge
Now your patient is ready for discharge.
Whether they need a S.N.F., home health,
D.M.E., or medications, the patients needs should be
met.