langcare-discharge-planning

name	langcare-discharge-planning
description	Performs comprehensive discharge readiness assessment by checking pending labs, imaging, medication reconciliation, follow-up appointments, patient education, DME orders, and home health referrals. Calculates LACE readmission risk index. Use when asked to check discharge readiness, discharge checklist, is patient ready for discharge, or prepare for discharge.

Discharge Planning Checklist

When to Use This Skill

Use when a clinician needs to verify discharge readiness by checking all CMS Condition of Participation requirements and calculating readmission risk.

Clinical Workflow

1. Use fhir_search to retrieve the current inpatient Encounter (status=in-progress, class=IMP)
2. Use fhir_search to check for pending ServiceRequest resources (active/draft labs, imaging, consults)
3. Use fhir_search to check for pending Observation results (status=preliminary/registered)
4. Use fhir_search to verify medication reconciliation: compare active MedicationRequest against MedicationStatement for discrepancies
5. Use fhir_search to check for scheduled follow-up Appointments (status=booked, date >= today)
6. Use fhir_search to check for patient education DocumentReference resources (LOINC 69981-9)
7. Use fhir_search to check for DME orders (DeviceRequest) and home health referrals (ServiceRequest)
8. Calculate LACE readmission risk index: L=length of stay, A=acuity of admission, C=comorbidities (Charlson), E=ED visits in 6 months (see references/lace-index.md)
9. Generate or update discharge CarePlan with pass/fail status for each requirement

FHIR Resources

• Encounter -- Current admission: period, class, reasonCode, admitSource
• ServiceRequest -- Pending orders: status, intent, code, category
• Observation -- Pending lab results: status
• MedicationRequest / MedicationStatement -- Medication reconciliation
• Appointment -- Follow-up scheduling: status, start, serviceType
• DocumentReference -- Patient education: type (LOINC 69981-9)
• DeviceRequest -- DME orders: status, code
• CarePlan -- Discharge plan with activities

FHIR Query Examples

Check Pending Orders

fhir_search(resourceType="ServiceRequest", queryParams="patient=[patient-id]&status=active,draft&encounter=[encounter-id]")

Check Follow-up Appointments

fhir_search(resourceType="Appointment", queryParams="patient=[patient-id]&status=booked,proposed&date=ge[today]")

Count ED Visits (6 months) for LACE

fhir_search(resourceType="Encounter", queryParams="patient=[patient-id]&class=http://terminology.hl7.org/CodeSystem/v3-ActCode|EMER&date=ge[6-months-ago]")

Clinical Guidelines

• CMS Conditions of Participation for Discharge Planning (42 CFR 482.43)
• Joint Commission standards for discharge planning
• LACE index for readmission prediction (van Walraven et al.)

Interpretation Guide

• Present as pass/fail checklist: pending labs/imaging, medication reconciliation, follow-up appointments, patient education, DME orders, home health referral
• LACE score: 0-4 low risk, 5-9 moderate risk, >=10 high risk for 30-day readmission
• Flag any FAIL item as a discharge blocker with specific action needed
• For high LACE scores (>=10), recommend enhanced post-discharge interventions: nurse phone call within 48h, transitional care management visit within 7 days

Safety

• Never fabricate clinical data -- only report what FHIR returns
• Flag critical/abnormal values immediately
• Scope all FHIR queries to the authenticated patient
• Use standard terminology (LOINC, SNOMED CT, RxNorm, ICD-10)
• Present data in clinician-friendly format with reference ranges