What is the purpose of physical therapy (PT) discharge planning?

Purpose of Physical Therapy Discharge Planning

The primary purpose of physical therapy discharge planning is to ensure a safe transition between care settings while maintaining continuity of care that optimizes rehabilitation potential, ensures proper secondary prevention, and improves patient outcomes. 1, 2

Core Components of Effective PT Discharge Planning

Early Initiation and Assessment

• Discharge planning should begin as early as possible after admission to any care setting, not delayed until late in the patient's stay 2
• Initial screening and assessment should identify the patient's functional status, mobility needs, and potential barriers to discharge 1
• Pre-discharge assessment should evaluate the patient's physical needs and functional abilities to determine readiness for transition 2

Interdisciplinary Collaboration

• Discharge planning requires well-organized collaboration between physical therapists, other healthcare professionals, patients, families, and caregivers 2
• The rehabilitation team (including physical therapists) evaluates the patient and develops a rehabilitation plan that addresses neurological deficits and appropriate rehabilitation needs 3
• Regular interprofessional meetings should be conducted to identify rehabilitation problems, set goals, monitor progress, and plan post-discharge support 3

Home and Environment Assessment

• A home visit by a healthcare professional should be conducted before discharge for patients where there are concerns regarding functional abilities that may affect safety 3
• Assessment of the home environment's safety and the need for equipment and home modifications is essential 3, 1
• Goal-oriented home visits help identify potential barriers and assess readiness for discharge 2

Patient and Caregiver Education

• Caregiver education and training to assist the patient with activities of daily living and increasing independence is a critical element 3
• Patients and caregivers must understand home exercise programs and activity modifications to continue recovery 1, 2
• Teaching patients and families how to identify and manage the nuances of their condition facilitates community reintegration and optimizes outcomes 3

Comprehensive Documentation and Communication

• Written discharge instructions should address functional ability, safety considerations, and action plans for continued recovery 2
• Clear communication channels must be established with the next provider of care 1, 2
• Timely transfer of relevant information to all healthcare providers involved in ongoing care is essential 2

Benefits of Effective Discharge Planning

Improved Patient Outcomes

• Reduced hospital length of stay and fewer readmissions at three months 2
• Greater caregiver preparedness for post-discharge care 1, 2
• Improved functional outcomes and increased cost-effectiveness when organized home health care is implemented 3
• For every 100 stroke residents receiving therapy-based rehabilitation services in the community, 7 patients would be spared a poor outcome 3

Enhanced Continuity of Care

• Effective discharge planning ensures patients receive specialized outpatient therapy-based interventions as needed 3
• Coordination of care beyond the inpatient setting and provision of community support services improve patient outcomes and satisfaction 3
• Early supported discharge programs can accelerate the transition from hospital to home through rehabilitation therapies delivered by an interprofessional team 3

Special Considerations

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 3

Patient-Centered Approach

• Goal-oriented discharge plans with target dates should be formulated collaboratively with patients and families 2
• Discharge planning should consider personal/psychosocial factors such as patient goals and social support 4
• Information provided at each phase should be relevant to the patient's and family's changing needs 3

Common Pitfalls to Avoid

• Failing to identify potential barriers to discharge early in the process 2
• Inadequate communication between healthcare team members during transitions of care 2
• Insufficient consideration of factors like pain, lack of confidence, and challenges with outdoor mobility that may affect home mobility 4
• Not providing comprehensive written discharge instructions 2

Physical therapy discharge planning is a critical process that significantly impacts patient outcomes, caregiver preparedness, and healthcare resource utilization. When implemented effectively, it ensures patients receive the appropriate level of care and support as they transition between settings.