Who has the final say about patient discharge from rehabilitation, the attending physician (AP) or the physical therapist (PT)?

The Attending Physician Has Final Authority for Patient Discharge from Rehabilitation

The attending physician has the final authority and responsibility for determining when a patient is ready for discharge from rehabilitation, although this decision should be made in collaboration with the multidisciplinary team, including physical therapists. 1

Decision-Making Authority in Rehabilitation Discharge

• The American Heart Association and American College of Cardiology guidelines strongly recommend that once a patient is medically stable, the primary physician should consult rehabilitation services to assess rehabilitation needs and recommend the most appropriate setting 2
• The attending physician is ultimately responsible for documenting medical necessity criteria for inpatient rehabilitation and making the final discharge decision 1
• While physical therapists provide critical assessment of functional status and rehabilitation progress, they serve in an advisory capacity to the attending physician 2
• The multidisciplinary rehabilitation team should provide coordinated input, but the attending physician integrates this information to make the final medical determination 1

Collaborative Approach to Discharge Planning

• A formal rehabilitation assessment by clinicians with expertise in rehabilitation should be conducted and documented for all patients before discharge 2
• Activities of daily living, communication abilities, and functional mobility should be evaluated by appropriate rehabilitation professionals to inform the physician's decision 2
• The physical therapist's assessment of the patient's functional status, strength, endurance, and safety is a crucial component of the discharge decision-making process 2
• Weekly multidisciplinary team meetings to discuss patient discharge timing improve functional outcomes 1

Common Pitfalls in Discharge Decision-Making

• Lack of communication between physicians and rehabilitation professionals can lead to disagreements about discharge readiness 3
• Studies show that patients and clinicians frequently disagree about when and where a patient will go after hospitalization, particularly for those discharged to skilled nursing facilities 3
• Financial considerations often become significant drivers of discharge decisions, which may conflict with clinical recommendations 4
• Delaying transfer to rehabilitation or discharge from rehabilitation when a patient is medically stable can lead to unnecessary costs, delayed functional recovery, and increased risk of hospital-acquired complications 1

Best Practices for Discharge Decision-Making

• The attending physician should document the medical necessity for continued rehabilitation or readiness for discharge in the medical record 2
• Explicit discharge criteria for patients should be established early in the rehabilitation course to mitigate variation in discharge practices 1
• Patient and family preferences should be considered in the discharge decision, but the attending physician must ensure the plan is medically appropriate 5
• Early supported discharge with home-based rehabilitation programs has been shown to be cost-effective for appropriate patients and should be considered when medically appropriate 1

Resolving Disagreements About Discharge Readiness

• When disagreements arise between the attending physician and physical therapist regarding discharge readiness, a structured discussion focusing on objective functional measures should occur 2
• If consensus cannot be reached, the attending physician's medical judgment prevails, as they bear ultimate responsibility for the patient's care 1
• Documentation of the clinical reasoning for the discharge decision is essential, particularly when there are differing opinions among the care team 2
• In cases of significant disagreement, involvement of the rehabilitation medical director or department chair may be appropriate to ensure the best patient outcome 1