What is physical therapy (PT) discharge planning?

Physical Therapy Discharge Planning

Physical therapy discharge planning is a comprehensive process that should be initiated as soon as possible after admission to any care setting, involving a well-organized collaboration between healthcare professionals, patients, families, and caregivers to ensure seamless transitions and continuity of care. 1, 2

Core Components of PT Discharge Planning

Initial Assessment and Planning

• Discharge planning should begin at the first point of contact with the healthcare system and continue throughout the continuum of care 2
• Create a patient-centered, culturally appropriate care plan that defines ongoing functional, rehabilitation, and mobility needs 1
• Formulate goal-oriented discharge plans with target dates in collaboration with patients and families 2
• Identify potential discharge barriers and patient needs early in the process to prevent delays 2, 1

Assessment Components

• Conduct pre-discharge assessment of patient's physical needs, functional status, and mobility 2
• Assess caregiver capacity and patient/family psychosocial needs that may impact recovery 2, 1
• Perform home assessment to identify necessary modifications for accessibility and safety 2, 1
• Use standardized assessment tools like the AM-PAC "6-Clicks" to help predict appropriate discharge destination with good accuracy 3

Discharge Planning Activities

• Arrange planned, goal-oriented home visits to identify potential barriers and assess readiness for discharge 2
• Provide caregiver training specific to the ongoing needs of the individual patient 2, 1
• Ensure patients and caregivers understand home exercise programs and activity modifications 1
• Regularly review and update the care plan at each transition point when changes in health status occur 2, 1

Communication and Documentation

Discharge Instructions

• Develop comprehensive written discharge instructions addressing 2, 1:
  • Current functional ability assessment
  • Safety considerations and precautions
  • Action plans for continued recovery
  • Home exercise program details
  • Follow-up care schedule
  • Provider contact information

Interprofessional Communication

• Ensure timely transfer of relevant information to all healthcare providers involved in ongoing care 2
• Conduct at least one formal interprofessional meeting per week to identify rehabilitation problems, set goals, monitor progress, and plan post-discharge support 2
• Designate a team member to facilitate transfer of patient-related information and referrals to appropriate follow-up services 2

Follow-up Planning

• Create a post-discharge follow-up plan initiated by a designated team member 2, 1
• Schedule follow-up appointments prior to discharge 1
• For patients discharged directly from emergency departments, address discharge planning needs and book appointments before they leave 2
• Consider referral to stroke navigators or similar roles where available to support self-management and healthcare system navigation 2

Outcomes and Benefits

• Physical therapists' discharge recommendations are implemented approximately 83% of the time, demonstrating their accuracy 4
• Patients are 2.9 times more likely to be readmitted when physical therapist discharge recommendations are not implemented and recommended follow-up services are lacking 4
• Effective discharge planning interventions have demonstrated reduced length of hospital stay, fewer readmissions at three months, and greater caregiver preparedness 2, 1

Decision-Making Process

• Physical therapists consider four key constructs when making discharge recommendations 5:
  • Patient's functioning and disability
  • Patient's wants and needs
  • Patient's ability to participate in care
  • Patient's life context

Common Pitfalls to Avoid

• Delaying the initiation of discharge planning until late in the patient's stay 1
• Failing to identify potential barriers to discharge early in the process 1
• Inadequate communication between healthcare team members during transitions of care 1
• Insufficient patient and caregiver education regarding home exercise programs and activity modifications 1
• Not providing comprehensive written discharge instructions 1