As a case manager, you are responsible for assisting with care transitions. Outline a discharge plan from the hospital to home care services for the following client:
Mr. Perez is a 72-year-old Puerto Rican male being discharged from your hospital with an exacerbation of Congestive Heart Failure. He has been hospitalized three times in the past 90 days. He lives alone and has limited family support. He understands English; however, he prefers to communicate in Spanish. This is his first referral to home care services. Medicare is his primary payor source. As you develop your discharge plan, identify areas that you will focus on with the home health agency to decrease the likelihood of readmission to the hospital.