We are all providing more short-term rehab services to individuals utilizing their Medicare A Skilled benefits. In addition, there are more community-based support services and housing options available for the elderly and disabled, regardless of their payer source. Thus, discharge planning is an active part of the assessment and care planning process. It may be most appropriate to have your social worker or designee assigned to code section Q1 of the MDS.

Section Q1 of the MDS seeks to identify residents who are potential candidates for discharge within the three months following each full assessment. This means that as the resident’s condition and other circumstances change, so may their discharge potential. For example, one resident may be able to return to his or her own home with full time assistance immediately following their Medicare A Skilled stay. Another resident with a similar functional status may not have the resources or support services to be able to return to their home until suitable alternative housing is available.

Be careful how you code each question in this section. They do not have to show agreement. “a.” requires a conversation about desire for discharge with the resident. You must code “yes” if the resident speaks of their wish to move out of your nursing home. This does not mean that you are promoting or creating unrealistic expectations. Likewise, because you may code “b.” as “no”, not having a support person who is positive towards discharge, does not negate the resident’s feelings or make discharge impossible.

Coding Q1c, discharge projection, is also subject to change over time. Some residents certainly come to us with the expectation of discharging within 30 days. However, not every one progresses as quickly as they hope and so that the time frame for discharge may be extended to 31-90 days or remains uncertain, or ‘open’, depending upon their health or external circumstances.

Although this section of the MDS does not have any triggers that would require a RAP, it should prompt you to develop a care plan that addresses the resident’s desire and/or needs. Many disciplines may play a role in the interventions, but a central point of communication/coordination, usually the social worker, is a necessity.