Week 1: Discharge Planning and Transitions of Care

what are transitions of care

moving to a different setting or discharge

why do we focus on transitions of care?

how will the next setting know what they need? How will the pt know how to continue their gains?

in transitions of care in acute care you must provide info on

follow up care, education on condition, education on AD and exercise, when to return to PCP/hospital

because pts need to continue therapy after hospital stay, we

are able to assist in determining a location for continued therapy

why are PTs involved in discharge planning

we view them in whole context (ICF/SDOH models)

if PT discharge recommendations are not followed, then

patient is 3x more likely to be readmitted

sending home rec without follow up

no need for PT, may need other services

sending them home to outpatient PT

2-3 days a week , have to be able to get there, need for specialized equiptment

sending them home for home health care

2-3 days a week, homebound, ability to assess function at home

inpatient rehab intensity

high intensity at LEAST 3 hrs/day 5 days a week

-at least 2 therapies (PT, OT, SLP)

inpatient rehab medical necessity

24 hour physician availability, active medical treatment

inpatient rehab length of stay

short term, 5 days-4 weeks

subacute rehab intensity

1 hr a day, at least 1 therapy (PT,OT, SLP)

subacute rehab medically stable

MD visits 1-2 times a week, transfer to hospital if have issues

subacute rehab length of stay

20-100 days, must be preceded by 3 days of acute care stay

main goal of subacute

return home

location of subacute rehab

often in nursing homes

goal of nursing home

maintain functions

long term stay of nursing homes

permanently resides there, now their home

long term acute care (LTAC) therapy

not the priority but may be getting it

2-5 x a week

LTAC medical needs

weaning from vent, complex wound care, long term IV antibiotics

LTAC length of stay

at least 25 days

LOOK OVER TUBES AND LINES

!!!! DO IT !!!!