What is the role of discharge planning in rehabilitation?

The Critical Role of Discharge Planning in Rehabilitation

Individualized discharge planning is essential in rehabilitation as it ensures a safe transition between care settings, reduces hospital length of stay and readmission rates, and optimizes rehabilitation potential while maintaining continuity of care. 1, 2

Core Components of Effective Discharge Planning

Early Assessment and Planning

• Discharge planning should begin as soon as possible after admission, not waiting until late in the patient's stay 2, 3
• The rehabilitation medicine team (physiatrist, speech, physical, and occupational therapists) should evaluate the patient during acute hospitalization to develop a rehabilitation plan addressing neurological deficits and appropriate needs 1
• Conduct at least one formal interprofessional meeting per week to identify rehabilitation problems, set goals, monitor progress, and plan post-discharge support 1

Interdisciplinary Collaboration

• Discharge planning requires a well-organized collaboration between healthcare professionals, patients, families, and caregivers 2, 3
• Discharge planners (social workers, case managers) integrate concerns and expectations of the interdisciplinary team with those of the patient and family 1
• The involvement of a designated discharge planning case manager is associated with significant reduction in unmet treatment needs 4

Pre-Discharge Assessment

• Conduct pre-discharge needs assessment to ensure smooth transition from rehabilitation back to the community 1
• Perform home assessment before discharge by an occupational therapist to evaluate safety, need for modifications, and equipment needs 1
• Assess caregiver capacity and patient/family psychosocial needs that may impact recovery 2, 3

Patient and Caregiver Education and Training

• Provide caregiver training on communication strategies, positioning, transfers, shoulder care, and promoting independence 1
• Educate patients and families on stroke pathology, prevention, signs and symptoms, treatment plan, and community resources 1
• Involve patient's family/caregiver in rehabilitation sessions to train them in assisting with functional activities 1

Benefits of Effective Discharge Planning

• Hospital length of stay and readmissions are significantly reduced for patients with medical conditions who receive individualized discharge planning (mean difference in length of stay -0.73 days, readmission rates reduced by 13%) 1, 5
• Organized home health care results in improved functional outcomes and increased cost-effectiveness compared to other discharge facility options 1
• Discharge planning may lead to increased satisfaction for patients, caregivers, and healthcare professionals 5

Special Considerations

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 1
• These technologies can be used for long-distance counseling, problem solving, educational sessions, and transmitting critical data 1

Caregiver Support

• Recognize that 12-55% of caregivers suffer from emotional distress, most commonly depression 1
• Include appropriate referrals to community resources, physician follow-up, support groups, governmental agencies, free services, and faith-based communities 1
• Regularly review individual patient and caregiver psychosocial and support needs 1

Communication and Documentation

• Provide comprehensive written discharge instructions addressing functional ability, safety considerations, and action plans for recovery 3
• Ensure timely transfer of relevant information to all healthcare providers involved in ongoing care 3, 6
• Establish clear communication channels with the next provider of care 2, 7

Common Pitfalls to Avoid

• Delaying the initiation of discharge planning until late in the patient's stay 3
• Inadequate communication between healthcare team members during transitions of care 6, 7
• Insufficient patient and caregiver education regarding home exercise programs and activity modifications 3
• Not addressing less obvious deficits (e.g., memory problems) which may pose as great a challenge as addressing needs related to overt physical limitations 1

Discharge Options for Severely Disabled Patients

• For patients too disabled to participate in or benefit from rehabilitation, options include skilled nursing care to assess for future rehabilitation potential, skilled nursing care alone, palliative care, or hospice care 1, 2