MDS Alert

Get resident off on the right foot at home--and show that you did.

Ensuring a resident's safe transition from SNF to home pays--in more ways than one.

Providing care and discharge planning validating that a resident can navigate his home environment helps prevent liability--and it counts toward rehab RUGs, if the resident qualifies.

Community reentry in Section P is covered under the [Medicare] RUG payment system (e.g. rehab therapies coded at P1b), says Reta Underwood, a consultant in Buckner, KY. Home visits by any of the therapy disciplines (occupational, speech or physical therapy) for discharge planning count as rehabilitation minutes, including transportation time if the therapist spends that time talking with the resident/family about discharge care needs, she says.

Cover the MDS bases: Check P1r to reflect training for reentry to the community, if the facility has addressed that issue, advises Underwood. "Social workers can also work with the resident/family in that area of care."

Interventions recorded at P2 (programs for mood, behavior, cognitive loss) can be modified to apply to the resident's functioning post-discharge--for example, behavior evaluations and mental health care, says Underwood.