Discharge Planning and Rural Health Care - Vocabulary Flashcards

Vocabulary flashcards covering key terms from notes on Critical Access Hospitals, rural health care, discharge planning, the IDEAL model, restorative and home care, and OASIS.

Critical Access Hospital (CAH)

A small rural hospital with limited beds (often ≤25), a 96-hour LOS cap for stabilization before transfer, located far from larger facilities; may operate rehab/psychiatric units up to 10 beds; staff includes physicians, NPs, and PAs; provides emergency services and basic diagnostics to stabilize before transfer.

Rural health care hub

A rural network of hospitals and clinics that enhances access, employs health care workers (often the area’s largest employer), coordinates care transitions, and links with urban systems to support rural populations.

Discharge planning

An interprofessional process to plan a patient’s continuing care after hospital discharge with the goal of reducing adverse events and readmissions; involves case managers, nurses, therapists, social workers, and physicians.

Posthospital destination

The setting to which a patient is discharged (e.g., home, rehab, SNF), chosen by the care team based on health needs, self-care capacity, caregiver availability, insurance, and residence.

Early mobility

Initiating mobility and activity early during hospitalization to support recovery and prepare for discharge.

IDEAL Discharge Planning Model

An AHRQ framework to engage patients and families in discharge planning to prevent adverse events and readmissions; emphasizes patient/family partnership, teach-back, plain language, and five key discussion areas.

IDEAL five key areas (discuss with patients/families)

Five topics to address to prevent home problems: describe life at home, review medications, highlight warning signs, explain test results, and make follow-up appointments; includes plain-language education and teach-back.

Teach-back

A communication technique in which clinicians ask patients to repeat back information to confirm understanding and identify gaps.

Barriers to discharge planning

Obstacles such as low health literacy, financial constraints, limited family support, cognitive/hearing impairments, unclear roles among team members, and resource shortages.

One-page discharge information page

A simplified, single-page handout provided at discharge to clearly convey the plan and key instructions.

OASIS (Outcome and Assessment Information Set)

Standardized core home health assessment used by Medicare-certified agencies to measure outcomes and risk; items cover home environment, informal caregivers, health and functional status, psychosocial factors, and health service use.

Home health care

Medically related professional and paraprofessional services and equipment delivered at a patient’s home to maintain health, prevent illness, diagnose/treat, rehabilitate, and provide palliative care; includes skilled nursing, therapy, and DME coordination; uses start-of-care and follow-ups; guided by OASIS.

Durable Medical Equipment (DME)

Medical equipment used at home (e.g., walkers, wheelchairs) to support treatment or rehabilitation.

Restorative care

Care aimed at restoring maximal functional status and independence after illness or injury; often provided in home or rehab settings and requires collaboration with patients and families.

Home health care

Skilled services and equipment provided in a patient’s home for health maintenance, prevention, diagnosis/treatment, rehabilitation, and palliation; delivered by a team including nurses, therapists, and aides; includes coordination of DME and ongoing assessments (start of care, 60-day follow-ups, and discharge) and uses OASIS.

Interprofessional discharge planning team

A collaborative group from multiple health disciplines (nurses, case managers, social workers, therapists, physicians, dietitians) working together to plan discharge and transitions.

Post-acute care

Care provided after hospital discharge to continue recovery and functioning, such as rehabilitation facilities or skilled nursing facilities.

Readmission

Returning to a hospital after discharge; reducing readmissions is a central aim of effective discharge planning.

Discharge planning for homelessness

Special considerations for patients who are homeless, including barriers to discharge care and housing; requires coordination with shelters and community services to ensure safe transitions.

Discharge planning begins at admission

The principle that discharge planning should start as soon as a patient is admitted to facilitate timely, safe, and coordinated transitions and shorten length of stay.