Discharge Planning in Rehabilitation: Purpose and Process
Discharge planning in rehabilitation is a well-organized collaborative process between healthcare professionals, patients, families, and caregivers that should begin as soon as possible after admission to ensure a safe transition between care settings while maintaining continuity of care that optimizes rehabilitation potential and ensures proper secondary prevention.
Definition and Purpose
- Discharge planning aims to reduce hospital length of stay, coordinate care, and ultimately improve patient outcomes by ensuring a safe transition between the acute care facility, rehabilitation, outpatient settings, primary care, and community 1
- The goal is to optimize rehabilitation potential, ensure proper secondary prevention, and maintain continuity of care while meeting the discharge needs of the patient and family 1
- It serves as a critical process to identify long-term needs and help organize provision of necessary services for patients transitioning from one care setting to another 1
When to Initiate Discharge Planning
- Discharge planning should be initiated as soon as possible after the patient is admitted to each stage and setting of care 1
- The process begins with assessment by each discipline on the rehabilitation team during the acute phase of care 1
- Early initiation helps identify potential discharge issues that could delay discharge and allows them to be addressed proactively 1, 2
Key Components of Effective Discharge Planning
Assessment and Care Plan Development
- Create a patient-centered, culturally appropriate care plan that defines ongoing medical, functional, rehabilitation, cognitive, communication, and psychosocial needs 1, 2
- 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
- Regularly review and update the care plan at each transition point when changes in health status occur 1, 2
Interdisciplinary Collaboration
- The discharge planning process should involve a well-organized collaboration between health professionals, patients, families, and caregivers 1
- The rehabilitation medicine team (physiatrist, speech, physical, and occupational therapists) evaluates the patient and develops a rehabilitation plan 1
- Discharge planners (social workers, case managers) integrate the concerns and expectations of the interdisciplinary team with those of the patient and family 1
- Nurses serve as liaisons between the patient/family and rehabilitation team and discharge planners 1
Home and Environment Assessment
- Perform home assessment to identify necessary modifications for accessibility and safety 1, 2
- Arrange planned, goal-oriented home visits to identify potential barriers and assess readiness for discharge 2
- Identify possible discharge issues and patient needs early in the process to prevent delays 1, 2
Education and Training
- Provide caregiver training specific to the ongoing needs of the individual patient 2
- Ensure patients and caregivers understand home exercise programs and activity modifications 2
- Teaching patients and families how to identify and deal with the nuances of their condition facilitates community reintegration and optimizes outcomes 1
Communication and Documentation
- Develop written discharge instructions addressing functional ability, safety considerations, and action plans for recovery 2
- Create a post-discharge follow-up plan initiated by a designated team member 2
- Establish clear communication channels with the next provider of care 2, 3
- Schedule follow-up appointments prior to discharge 2
- Ensure timely transfer of relevant information to all healthcare providers involved in ongoing care 2, 3
Benefits of Effective Discharge Planning
- Reduced hospital length of stay and readmission rates for patients with medical conditions 1, 4
- Improved patient and caregiver satisfaction with healthcare received 4
- Greater caregiver preparedness for post-discharge care 1, 2
- Improved functional outcomes and increased cost-effectiveness when organized home health care is implemented 1
Common Pitfalls and How to Avoid Them
Delaying the initiation of discharge planning until late in the patient's stay 2
- Solution: Begin discharge planning at admission with input from all team members
Inadequate communication between healthcare team members during transitions of care 2, 3
- Solution: Implement structured discharge communication tools that ensure timely and effective transfer of relevant patient information
Insufficient patient and caregiver education regarding home exercise programs and activity modifications 2
- Solution: Provide comprehensive education with written materials and demonstration
Not addressing the needs for less obvious deficits (e.g., memory problems) 1
- Solution: Conduct thorough cognitive assessments and include strategies for managing cognitive deficits in discharge plans
Failing to identify potential barriers to discharge early in the process 2
- Solution: Conduct early assessments to identify potential issues and develop mitigation strategies
Alternative Methods for Discharge Support
- Consider alternative methods of communication and support such as telephone visits, telehealth, or web-based support, particularly for patients in rural settings 1
- These technologies can be used for long-distance counseling, problem-solving, educational sessions, and transmitting critical health data 1