What is the best course of action for a patient with a complex medical history, who is currently stable and making progress towards their functional and restorative goals, but requires close monitoring for potential complications?

Management of Stable Patients with Complex Medical History in Skilled Nursing Facilities

Continue frequent physician visits (at minimum weekly) with structured interdisciplinary team collaboration, systematic reassessment of all health domains at each encounter, and proactive medication reconciliation to prevent complications and hospital readmissions. 1

Structured Follow-Up Schedule

• Visit patients with complex medical histories at least weekly during skilled nursing admission, as frequent monitoring enables early identification of complications before they progress to requiring hospitalization. 1
• Schedule visits more frequently (2-3 times weekly) if the patient has multiple chronic conditions requiring active medication adjustments or recent acute decompensation. 1

Systematic Assessment at Each Visit

Medical Domain Reassessment

• Perform medication reconciliation at every visit by comparing the electronic medication list against actual medications the patient is taking (including prescription, over-the-counter, and supplements), as medication discrepancies are a leading cause of preventable adverse events. 1
• Reassess adequacy of chronic disease management including blood pressure control, glycemic control in diabetes, and ventricular rate control in atrial fibrillation, as suboptimal management at discharge is a major contributor to readmissions. 1
• Review recent laboratory results and vital sign trends to detect early deterioration before clinical symptoms manifest. 1

Functional Status Monitoring

• Use standardized functional assessment tools (such as the Functional Independence Measure) at regular intervals to objectively document progress toward rehabilitation goals and identify plateaus requiring intervention adjustment. 1, 2
• Assess aerobic capacity, balance, gait, activities of daily living, and instrumental activities of daily living at each visit, as these directly predict discharge readiness and risk of falls. 1

Patient Engagement and Goal Alignment

• Review and update patient-centered functional goals every 1-2 weeks through collaborative discussion with the patient, family, and interdisciplinary team, as goal setting improves patient satisfaction and rehabilitation outcomes. 3, 4, 5
• Document specific, measurable goals in the medical, behavioral, and social domains, as patients typically have goals across all three areas. 3
• Provide reminders and feedback on goal progress, as this enhances goal achievement and patient engagement in therapy. 4

Advance Care Planning

• Complete an advance directive with the patient and family within the first 2 weeks of admission if not already documented, ensuring a copy is placed in the chart and provided to the family. 1
• Reassess goals of care and appropriateness of advanced therapies or end-of-life discussions when functional status plateaus or declines despite optimal management. 1

Interdisciplinary Collaboration Framework

• Conduct formal interdisciplinary team conferences at least every 2 weeks to review progress, adjust the care plan, and ensure all team members (physical therapy, occupational therapy, speech therapy, nursing, pharmacy) are aligned on goals and interventions. 1
• Communicate directly with the patient's primary care physician and specialists regarding significant changes in status, medication adjustments, or discharge planning. 1

Preventive Interventions

• Ensure influenza and COVID-19 vaccinations are current, as these reduce morbidity and mortality in high-risk populations. 1
• Implement fall prevention strategies including environmental modifications, assistive device optimization, and medication review to eliminate sedating agents when possible. 1
• Monitor for signs of depression and cognitive decline, as these are common in rehabilitation settings and negatively impact functional outcomes. 1

Discharge Planning Preparation

• Begin discharge planning discussions early in the admission, addressing the patient's functional abilities, home environment safety, caregiver support, and outpatient follow-up arrangements. 1
• Provide written discharge instructions covering activity level, diet, medications (with purpose, dose, frequency, and side effects), follow-up appointments, weight monitoring if applicable, and warning signs requiring medical attention. 1
• Schedule outpatient follow-up within 2 weeks of discharge for higher-risk patients or 2-6 weeks for lower-risk patients. 6

Critical Pitfalls to Avoid

• Never discharge patients before optimal volume status is achieved in heart failure, adequate blood pressure control is established, or acute medical issues are fully resolved, as premature discharge is a leading cause of 30-day readmissions. 1
• Do not rely solely on blood pressure values to guide management; assess for signs of hypoperfusion (cool extremities, decreased urine output, altered mentation) when considering hemodynamic interventions. 1
• Avoid prescribing medications without checking formulary coverage, as out-of-pocket costs reduce adherence and worsen outcomes. 1
• Never defer comprehensive baseline assessment, as incomplete initial evaluation prevents accurate monitoring of disease progression and response to treatment. 7

Special Considerations for High-Risk Subgroups

• Patients with mental health conditions and those living alone are significantly less likely to achieve goal progress and require enhanced support structures and more frequent monitoring. 3
• Patients requiring inotropic support during hospitalization require cautious beta-blocker initiation and close monitoring for decompensation. 1