Q0400A. Active Discharge plan for return to community, Step-by-Step

Step-by-Step Coding Guide for Item Set Q0400A: Active Discharge Plan for Return to Community

This guide is crafted to assist with the accurate coding of an active discharge plan for a resident's return to the community, as outlined in Q0400A of MDS 3.0.

1. Review of Medical Records

• Objective: To identify evidence of an active discharge plan aimed at facilitating the resident’s return to the community.
• Key Points:
  • Examine the resident's care plan, social service notes, therapy progress notes, and discharge planning documents for details on plans for the resident's return to the community.
  • Look for multidisciplinary team meetings or discussions that have focused on discharge planning, including goals, services needed post-discharge, and community resources.

2. Understanding Definitions

• Objective: Clarify the concept of an "Active Discharge Plan for Return to Community."
• Key Points:
  • Active Discharge Plan: Refers to a structured plan involving the resident, care team, and possibly the resident's family, designed to enable the resident's successful transition from the facility to the community. This plan should include specific goals, services, and supports needed post-discharge.

3. Coding Instructions

• Objective: Provide guidance on accurately coding the presence of an active discharge plan.
• Key Points:
  • Code 1: If there is a documented active discharge plan that includes specific goals and necessary services/supports for the resident’s return to the community.
  • Code 0: If no active discharge plan is documented or if the plan does not meet the criteria for an active plan aimed at returning to the community.

4. Coding Tips

• Ensure that the discharge plan is comprehensive, addressing the resident's healthcare needs, social supports, housing, and any community services required.
• Regularly review and update the discharge plan to reflect the resident's current needs and progress.

5. Documentation

• Clearly document all aspects of the discharge plan, including goals, anticipated needs, referrals to community services, and any coordination with community providers or agencies.
• Include documentation of discussions with the resident and their family or representatives about the discharge plan.

6. Common Errors to Avoid

• Failing to document an active discharge plan even when one exists or is in the process of being developed.
• Overlooking the need to update the discharge plan as the resident’s situation or needs change.

7. Practical Application

• Scenario: A resident recovering from hip surgery has been participating in physical therapy with the goal of returning home. The care team develops an active discharge plan that includes home modifications, outpatient physical therapy referrals, a home health aide, and transportation to follow-up medical appointments. This comprehensive plan is documented in the resident’s care plan and discussed with the resident and their family.

The Step-by-Step Coding Guide for item Q0400A in MDS 3.0 Section Q is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.