Resident Information:

• Name: Michael Johnson
• ID: 862543
• Date of Assessment: YYYY-MM-DD
• Room Number: 305

Assessment Team:        

• Primary Nurse: Lisa Hamilton
• MDS Coordinator: Thomas Wright
• Social Worker (SW): Angela Davis
• Physical Therapist (PT): Omar Jenkins
• Occupational Therapist (OT): Emily Clark

Care Area Assessed:

• Specify the care area: Return to Community Referral

Step 1: Triggered Care Areas

• Triggered by Michael's expressed desire and readiness to consider returning to independent living in the community following a period of rehabilitation for a hip fracture.

Step 2: Review of MDS 3.0 Findings

• Michael has shown significant progress in physical rehabilitation and has reached a level of independence in ADLs that supports a potential transition back to community living.

Step 3: Detailed Assessment

• Clinical findings: Assessment of Michael's physical recovery, including mobility and self-care capabilities, confirms his potential for successful community reintegration.
• Review of medical records: Notes on Michael's rehabilitation progress, previous living situation, and social supports available in the community.
• Consultations with interdisciplinary team members: Discussions on necessary preparations for discharge, including home safety evaluations, outpatient therapy needs, and community support services.
• Resident and family interviews: Gather insights on Michael's support system, personal goals, and concerns about returning to independent living.

Step 4: Problem Identification

• Identified challenges include ensuring Michael's home environment is safe and accessible, coordinating continued outpatient therapy services, and connecting him with community resources for additional support.

Step 5: Care Planning

• Goal: To develop a comprehensive discharge plan that supports Michael's successful transition to community living, addressing his healthcare needs, home environment modifications, and social support systems.
• Interventions:

• • Conduct a home safety evaluation and recommend necessary modifications to facilitate mobility and daily activities.
  • Arrange for continued outpatient PT and OT to support ongoing physical recovery and independence.
  • Coordinate with community agencies to provide Michael with access to supportive services, including transportation, meal delivery, and social engagement opportunities.
  • Develop a follow-up plan with the SW to monitor Michael's adjustment to community living and address any emerging needs.
  • Educate Michael and his family on available resources, emergency preparedness, and strategies for maintaining health and well-being in the community.

• Responsible Staff: SW, PT, OT, Nursing Staff
• Timelines: Immediate initiation of discharge planning with targeted completion date prior to Michael's anticipated discharge, ensuring all services and supports are in place.

Step 6: Interdisciplinary Team Review

• The team collaborates on Michael's discharge plan, ensuring a coordinated approach that leverages the expertise of each discipline to facilitate a smooth transition to the community.

Step 7: Resident and Family Engagement

• Engaging Michael and his family in the discharge planning process ensures they are informed, prepared, and confident in the transition plan, fostering a sense of empowerment and ownership over the process.

Step 8: Monitoring and Reassessment

• Short-Term: Weekly check-ins by the SW post-discharge to assess adjustment, address any concerns, and modify the plan as needed.
• Long-Term: Monthly follow-up for the first three months post-discharge, then as needed, to ensure Michael's continued well-being and satisfaction with community living.

Documentation and Signatures:

• Signature of MDS Coordinator: Thomas Wright, Date: YYYY-MM-DD
• Signature of Primary Nurse: Lisa Hamilton, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

Scheduled Date: YYYY-MM-DD to review the effectiveness of the discharge process, discuss any challenges encountered by Michael post-transition, and identify opportunities for improvement in future community reintegration efforts.