This module addresses best practice strategies that can be adopted by home based care organizations (home health and hospice) to support patients after discharge to the community. Home based health care organizations have long worked to reduce hospital readmissions. Now, the Discharge to Community performance measure adopted under the IMPACT Act requires that agencies also anticipate and plan to prevent readmissions after discharge from home health. 2017 Conditions of Participation for Home Health also emphasize comprehensive, patient-centered discharge planning.

Best practice recommendations for successful Discharge to Community include:

• Implement strategies to prevent readmissions (See VNAA Preventing Readmissions)
• Improve 'upstream' handoffs:enhance discharge planning and ensure appropriate placements from hospitals
• Improve 'downstream' handoffs: Enhance discharge process from home health to include social work referral, home evaluation and formalized handoffs to community organizations
• Standardize home health discharge with emphasis on readiness to live in the community
• Involve social work to develop and implement community discharge plan

We examine these strategies in the Tools and Intervention section, which includes recommendations for preventing readmissions and improving discharge to community. Visit Discharge to Community Measures for details on the IMPACT Act measure and related Star Ratings measures. See VNAA Blueprint module on 5-Star Best Practices for information on quality improvement approaches, improving documentation, and improving staff training. Strategies for improving the continuum of care for palliative and hospice services are addressed in the module, Improving the End of Life Continuum. 

The Discharge to Community module was reviewed by a joint VNAA and the Alliance for Home Health Quality and Innovation work group. We appreciate input of the expert Discharge to Community Work Group. We encourage users to visit other sections of the VNAA Blueprint for Excellence to drill down on related issues.