What is the discharge planning process in physical therapy?

Discharge Planning Process in Physical Therapy

The discharge planning process in physical therapy should begin 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 Discharge Planning

Initial Assessment and Planning

• Discharge planning should be initiated immediately upon admission to each stage and setting of care 3
• 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 collaboratively with patients and families 3, 1
• Identify potential discharge issues and patient needs early in the process to prevent delays 3, 1

Ongoing Assessment and Preparation

• Conduct pre-discharge assessment of patient's physical needs, functional status, and mobility 1, 2
• Assess caregiver capacity and patient/family psychosocial needs that may impact recovery 3, 1
• Perform home assessment to identify necessary modifications for accessibility and safety 3, 1
• Arrange planned, goal-oriented home visits to identify potential barriers and assess readiness for discharge 3, 1
• The rehabilitation team should conduct at least one formal interprofessional meeting per week to monitor progress and plan support after discharge 3

Education and Training

• Provide caregiver education and training specific to the ongoing needs of the individual patient 3, 1
• Ensure patients and caregivers understand home exercise programs and activity modifications 1, 2
• Introduce patients and families to resources that will enable self-management and navigation through the healthcare system 3

Communication and Documentation

• Develop written discharge instructions addressing functional ability at discharge, risks and safety considerations, action plans for recovery, and follow-up care 3, 1
• Create a post-discharge follow-up plan initiated by a designated team member, such as a case manager or stroke navigator 3, 1
• Establish clear communication channels with the next provider of care 1, 4
• Schedule follow-up appointments prior to discharge 3, 1

Interdisciplinary Collaboration

• The discharge planning process should be a well-organized collaboration between physical therapists, other health professionals, patients, families, and caregivers 3, 1
• A designated member of the care team should facilitate transfer of patient-related information and patient referrals to appropriate follow-up services 3
• Consider designating a discharge coordinator or case manager to facilitate communication between healthcare providers 4
• The American Heart Association recommends implementing a formal interdisciplinary care plan that clearly outlines roles and responsibilities of all team members 4

Documentation Requirements

• Prepare comprehensive written discharge instructions including current functional ability assessment, safety considerations, precautions, and action plans for continued recovery 1
• Ensure timely transfer of relevant information to all healthcare providers involved in ongoing care 3, 1
• The information transferred should be comprehensive with all relevant patient information, medications, progress to date, planned appointments, and ongoing recovery needs and goals 3
• A formal, typed, detailed discharge summary should be sent to the primary care physician 3

Benefits of Effective Discharge Planning

• Discharge planning interventions have demonstrated reduced hospital length of stay and fewer readmissions at three months 1, 5
• Greater caregiver preparedness for post-discharge care 1, 2
• Improved functional outcomes and increased cost-effectiveness when organized home health care is implemented 2
• A structured discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and readmissions for older patients 5

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, 4
• Insufficient patient and caregiver education regarding home exercise programs and activity modifications 1
• Not providing comprehensive written discharge instructions 1
• Failing to consider the patient's personal and psychosocial factors when planning discharge 6

Decision-Making Process for Discharge Recommendations

• Physical therapists consider four key constructs when making discharge recommendations: patients' functioning and disability, patients' wants and needs, patients' ability to participate in care, and patients' life context 7
• Information is filtered through therapists' experiences and modified by the healthcare team's opinions and by healthcare regulations 7
• Clinicians place more emphasis on individual needs and goals of the patient than on specifying objective performance criteria that must be met 6
• Factors such as caregiver availability, complexity of follow-up care needs, physical functioning, and compliance influence the choice of discharge option 8