DISCHARGE RISK ASSESSMENT - to be completed at 2 days prior to discharge

CHECK ALL THAT APPLY NOTIFY AGENCIES UPON COMPLETION:

 Lives at home with limited or no community support HOME HEALTH AGENCY NAME / NOTIFIED
 Requires assistance with medication management
_______________________________________________________________
 Polypharmacy (more than 7 medications)
 History of mental illness  Called DATE/TIME_______________
 Issues with health literacy  FAX’d DATE/TIME_______________
 Requires assistance with ADLs/IADLs
SKILLED NURSING FACILITY NAME / NOTIFIED:
 Cognitive impairment
 End stage conditions
_______________________________________________________________
 Diagnosis of CHF/COPD/DM/HIV-AIDS
 Incontinent  Called DATE/TIME_______________
 Acute/chronic wound or pressure ulcer  FAX’d DATE/TIME_______________
 History of falls
HOSPICE NAME / NOTIFIED:
 Decreased adherence to treatment plan
 Repeat hospitalization / ED visits _______________________________________________________________
 Requires assistance with managing O2 and/or nebulizer
 Called DATE/TIME_______________
Total # checked _______  FAX’d DATE/TIME_______________

Score ≥ 5 PCP NAME / NOTIFIED:

The patient is HIGH RISK for re-hospitalization. Refer to Home care
service, SNF, or Hospice. OR ________________________________________________________________

 Called DATE/TIME_______________
Score 2-4
 FAX’d DATE/TIME_______________
The patient is MODERATE RISK for re-hospitalization. Refer to Home care
service prior to D/C.
COMPLETE BY_______________________________________________
Score < 2
DATE/TIME________________________
The patient is LOW RISK for re-hospitalization. Discharge home.

This material was prepared by Mountain-Pacific Quality Health, the Medicare Quality Improvement Organization for Patient Sticker
Montana, Wyoming, Hawaii and Alaska, under contract with the Centers for Medicare & Medicaid Services (CMS), an
agency for the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS
policy. 10SOW-MPQHF-AS-IC-13-01