As used in this chapter, "at home care plan" means any plan that serves to describe the after care needs of a patient upon discharge from a hospital to the patient's residence, if the at home care plan:

1. (1) is developed by:

   1. (A) a registered nurse licensed under IC 25-23 , social worker licensed under IC 25-23.6 , or other licensed health care professional; or
   2. (B) an individual supervised by a licensed registered nurse, licensed social worker, or other licensed health care professional;
2. (2) is based on an evaluation of the patient's need for after care, taking into consideration the patient's functional status and cognitive ability, including the patient's capacity for self care; and

3. (3) includes contact information for hospital personnel or the patient's physician if the patient or the patient's lay caregiver designated under this chapter has questions regarding the patient's after care.

   The term includes a discharge plan prepared for the patient that is developed under the discharge planning requirements of the Medicare program's conditions of participation.

As added by P.L.137-2015, SEC.6.