Abstract
Medicare relies upon an interprofessional team of home health (HH) clinicians to evaluate beneficiary needs and to decide to discharge from skilled HH or recertify patients for an additional 60-days. However, there are no national, empirically derived decision support tools to assist in making these important decisions and getting it wrong can result in adverse events after discharge. Two studies, one quantitative and one qualitative informed the research questions of what factors are associated with poor HH discharge outcomes and readiness for discharge. The quantitative OASIS data elements were found to not be helpful predictors for identifying which patients are likely to have adverse outcomes. However, the qualitative interview themes identified patient safety, independence and caregiver availability as critical for determining readiness for a safe discharge. These findings inform the development of an evidence-based discharge decision support tool to provide a standardized approach to determine readiness for discharge from HH.