The Purpose of Physical Therapy Discharge Planning
Physical therapy discharge planning aims to ensure a safe transition between care settings, optimize rehabilitation potential, and maintain continuity of care while meeting the needs of the patient and family. 1
Core Components of Effective PT Discharge Planning
Early Initiation and Interdisciplinary Collaboration
- Discharge planning should begin as early as possible after admission to any care setting 2
- The process requires well-organized collaboration between physical therapists, other health professionals, patients, families, and caregivers 1, 2
- Rehabilitation unit teams should conduct at least one formal interprofessional meeting per week to identify rehabilitation problems, set goals, monitor progress, and plan post-discharge support 3
Comprehensive Assessment
- Pre-discharge assessment of the patient's physical needs, functional status, and mobility is essential 1, 2
- Assessment of the safety of the patient's home environment and need for equipment and home modifications should be conducted 3
- Home visits by healthcare professionals are recommended when there are concerns regarding changes in functional abilities that may affect patient safety 3
Patient and Caregiver Education
- Caregiver education and training to assist the patient with activities of daily living and increasing independence is a critical component 3, 1
- Patients and caregivers must understand home exercise programs and activity modifications 2
- Teaching patients and families how to identify and manage the nuances of their condition facilitates community reintegration and optimizes outcomes 1
Care Plan Development and Documentation
- Create a patient-centered, culturally appropriate care plan that defines ongoing functional, rehabilitation, and mobility needs 1, 2
- Develop written discharge instructions addressing functional ability, safety considerations, and action plans for recovery 1, 2
- Establish clear communication channels with the next provider of care 1, 2
Benefits of Effective Discharge Planning
Improved Patient Outcomes
- Reduced hospital length of stay and readmission rates 1
- Greater caregiver preparedness for post-discharge care 1
- Improved functional outcomes and increased cost-effectiveness 1
- Patients are 2.9 times more likely to be readmitted when the therapist's discharge recommendations are not implemented and recommended follow-up services are lacking 4
Continuity of Care
- Ensures proper coordination between acute care, rehabilitation, outpatient settings, and community services 1
- Facilitates appropriate referrals to specialized outpatient therapy-based interventions 3
- Patients and families are introduced to resources that enable self-management and navigation through the healthcare system 3
Alternative Support Methods
- Consider alternative methods of communication and support such as telephone visits, telehealth, or web-based support, particularly for patients in rural settings 3, 1
- These technologies can be used for long-distance counseling, problem-solving, and educational sessions 3
Common Pitfalls to Avoid
- Delaying the initiation of discharge planning until late in the patient's stay 2
- Failing to identify potential barriers to discharge early in the process 2
- Inadequate communication between healthcare team members during transitions of care 2
- Insufficient patient and caregiver education regarding home exercise programs and activity modifications 2
- Not providing comprehensive written discharge instructions 2
Evolution of Discharge Decision-Making
- The discharge decision-making process changes with clinical experience 5
- With experience, physical therapists place greater emphasis on the patient's role in rehabilitation and increasingly promote self-management goals 5
- Experience affects how therapists conceptualize their roles in discharge decisions and how they negotiate goals with patients 5