PHT.5222C - Acute Care Discharge Planning and Communication

PHT.5222C - Acute Care Discharge Planning and Communication

Introduction to Acute Care Discharge Planning

  • Role of the Physical Therapist: Discussed in the acute care discharge planning process.

  • Objectives for the Lecture: Understanding the discharge planning process and its components.

Definition of Discharge Plan

  • What is a Discharge Plan?

    • A discharge plan is initiated early in the rehabilitation process.

    • Intensifies as rehabilitation goals and expected outcomes are approached.

    • Involves an Interdisciplinary Team:

    • Factors considered include:

      • Patient's cognitive and physical functioning.

      • Social and financial status.

      • Environmental concerns.

      • Availability of formal and informal care.

Elements of Discharge Planning

  • Detailed in the O'Sullivan physical rehabilitation textbook.

    • Multifaceted Nature:

    • Involves integration of patient information for sound discharge recommendations.

    • Requires insights from interdisciplinary team members.

    • Key Considerations:

    • Optimal patient support.

    • Appropriate discharge settings.

    • Avoidance of readmission.

Role of Physical Therapists in Discharge Planning

  • Decision Making Based on Several Factors:

    • Patient's function and level of disability.

    • Patient's wants and needs.

    • Patient's ability to participate in their own care.

    • Life context of the patient.

  • Scope of Practice and Guide to Physical Therapy Practice:

    • Physical therapists provide planned care that identifies anticipated goals and expected outcomes, alongside patient expectations.

    • Physical therapists also recommend appropriate follow-ups or referrals for discharge.

Importance of Functional Assessment

  • Assessment of Functional Abilities:

    • Crucial in determining discharge needs, with emphasis on the valuing therapist's recommendations by decision makers.

  • Study Findings:

    • Research by Smith-Fields and Fernandez shows:

      • Physical therapist recommendations are considered 83% of the time.

      • Non-adherence to recommendations increases readmission risk by 2.9 times.

Expectations of Entry-Level Physical Therapists

  • Key Aspects of Discharge Planning:

    • Identification and recommendation of appropriate discharge settings:

    • Return home without physical therapy.

    • Go home with home health physical therapy.

    • Transfer to skilled nursing facility.

    • Move to inpatient rehabilitation facility.

    • Access long-term acute care facility.

    • Home with outpatient physical therapy or extended care facility without therapy.

Recommendations for Home Health Physical Therapy

  • Criteria for Home Health Services:

    • Patient must be considered homebound.

    • Patients must meet Medicare requirements:

      • Must either have an illness/injury.

      • Use special transportation or require assistance.

      • Have conditions contraindicating leaving home.

  • Definition of Homebound:

    • Criterion 1: Requirement of only one of these causes to meet homebound status.

    • Criterion 2: Requires both conditions to confirm homebound status:

    • Normal inability to leave home.

    • Leaving home involves considerable effort.

    • Exceptions to Homebound Status:

    • Attendance at religious services or healthcare visits.

    • Short duration absences, e.g., from medical appointments or day care programs.

Skilled Nursing Facility Recommendations

  • Purpose: For individuals needing nursing and rehabilitation at the inpatient level.

  • Characteristics:

    • Requires assistance for fewer than 3 hours/day of physical therapy.

    • Goals for return home remain crucial.

Inpatient Rehabilitation Facilities

  • Indications for Admission:

    • Patients with complex medical, nursing and rehabilitation needs requiring inpatient care.

  • Therapy Requirement:

    • Requires at least two therapy disciplines.

    • Able to tolerate intensive rehabilitation (3+ hours of therapy daily).

Long-Term Acute Care Facilities

  • Patient Profile:

    • Medically complex patients not able to return home.

    • Considered less medically stable than those in inpatient rehabilitation.

    • Expected to need long-term care with less intensity but frequent therapy sessions focused on mobility and activity tolerance.

Outpatient Physical Therapy

  • Criteria for Services:

    • Patients who are safe to return home yet require skilled physical therapy services.

    • They are not considered homebound and can travel to an outpatient facility.

Additional Recommendations

  • Need for Supervision or Assistance:

    • Physical therapists recommend based on existing support systems (family, friends) and financial realities.

  • Durable Medical Equipment (DME) Considerations:

    • Some patients might need to procure new DME based on recommendations.

    • If transferring to another facility, existing equipment is utilized; recommendations for DME are made upon discharge home.

Importance of Understanding Equipment

  • Assistive Devices and Applications:

    • Importance of familiarity with different types of assistive devices, adaptations, and equipment covered in previous lectures and PCM 1.

Conclusion

  • Acknowledgment and thankfulness for participation in the presentation.