Discharge Planning

Discharge Planning
Follow these rules of thumb for a smooth transaction.

Discharge planning should start as soon as a patient is admitted to the long-term care facility. It can proceed smoothly, as in the case of a healthy patient with elective surgery who has a capable spouse at home. On the other hand, it can be frustrating and time-consuming.

Rules of Thumb
Consider these four rules of thumb for facilitating successful discharges from the skilled nursing facility.

1. Discharge planning requires an interdisciplinary approach. For example, a patient we'll call Larry was telling his therapists that he wanted to go home after a lengthy nursing home stay for treatment of severe leg wounds. He had regained independent ambulation indoors.

His PT supported his goal of independent living until the resident care manager pointed out that Larry was in a manic phase of his bipolar disorder. When he was in a depressive phase, he had a history of caring poorly for himself. She favored long-term care placement for Larry, saying his leg wounds would surely recur if he went home.

Each member of the interdisciplinary team has a unique perspective and brings facts and knowledge to complete the picture. We recommend using a discharge planning worksheet. Information pertinent to discharge can be summarized on one page.

2. Think twice about discharging patients just before a return visit to their doctor. In some cases the doctor will request continued physical therapy, or ask for changes or additions to the treatment program. Sometimes one of the members of the patient's care team will discover a new medical problem, or a new medication might be prescribed.

3. Assume that patients know little or nothing about the discharge planning process. They and their significant others will want to know how long they will need to stay and who decides when they can go home. Take the time to educate. Tell patients what goals they need to achieve to be safe. Encourage their participation in planning for discharge. If the patient has an HMO, explain the preauthorization process. Also remember to discuss the role of home health services and outpatient physical therapy in continued care.

4. Be as specific as possible when recommending durable medical equipment, and let patients and their families know how to obtain it. Let them know if your facility has a designated person, usually a social worker, who can assist in ordering the equipment. Make it clear which items are covered by insurance and which aren't.

Medicare and Medicaid rules for coverage of DME do change frequently. There are four insurance companies, one for each Medicare region, that function as DMERCs and process DME, prosthetics, orthotics and supplies claims for the Medicare program.

Multiple Timelines
Discharge planning is complex and involves interplay among multiple timelines that all converge toward a discharge date. These timelines include:

  • expected recovery time for the patient's diagnosis;
  • how long the patient wishes to stay (the only factor in some cases);
  • how long a family caregiver thinks the patient should stay;
  • rate of progress toward therapy goals;
  • number of days the payer will reimburse;
  • rate of success of nursing interventions such as wound care; and
  • length of time it takes for social services to find alternate placement and community services for a homeless patient, or a patient who can't safely return home.

A coordinated discharge plan, with patient and family involvement, confers intangible benefits, such as reduction in worry and anxiety for all, as well as tangible benefits of improved health, mobility and safety.

Bob Thomas, MS, PT, is a geriatric physical therapist and director of rehab services for Avamere Health in Oregon and Washington. He lectures nationally for GREAT Seminars on rehab solutions for the frail elderly and is an adjunct professor at Pacific University. Emi Storey, MA, PT, is employed by Avamere Rehab and serves as physical therapist and therapy program manager at Porthaven Care Center in Portland, OR.


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