What is the most appropriate discharge plan for an elderly patient with right lower extremity cellulitis, congestive heart failure (CHF), recent acute confusion, and a Do Not Resuscitate (DNR) status, who has demonstrated functional decline but is mobilizing with a walker and has an improved mental status?

Discharge Planning for Elderly Patient with Cellulitis, CHF, and Functional Decline

This patient should be discharged to a skilled nursing facility (SNF) rather than directly home, given the combination of functional decline requiring walker assistance, recent acute confusion, modest CHF requiring ongoing monitoring, and active cellulitis treatment. 1

Key Clinical Considerations Supporting SNF Placement

Functional Status and Safety Assessment

• The patient demonstrates significant functional decline with inability to sit up independently and requires walker assistance for mobility, which are critical indicators that independent community living may not be safe at this time 1, 2
• Despite improvement in mental status, the recent episode of acute confusion with vomiting indicates vulnerability to decompensation and need for closer monitoring than typically available at home 2, 3
• The patient's intermittent refusal of meals, medications, and care suggests potential adherence challenges that require structured supervision 3

Active Medical Issues Requiring Ongoing Management

• Right lower extremity cellulitis requires completion of antibiotic therapy with monitoring for treatment response and potential complications 1
• The modest CHF on chest x-ray necessitates daily weight monitoring, fluid balance assessment, and potential diuretic adjustment—tasks difficult to manage reliably at home without support 1, 4, 5
• Patients with CHF should not be discharged while still congested and require establishment of a stable oral medication regimen for at least 48 hours before discharge 4, 5

Discharge Criteria That Must Be Met Before SNF Transfer

Clinical Stability Requirements

• Patient must be hemodynamically stable with acceptable oxygen saturation on 2L oxygen (currently met) 1, 4
• Mental status should remain clear and appropriate (currently improved and stable) 1
• Volume status should be optimized with resolution of acute CHF exacerbation 4, 5
• Cellulitis should show clinical improvement with established antibiotic regimen 1

Medication Reconciliation and Optimization

• Complete medication reconciliation with clear documentation of all current medications, doses, and administration schedule 1, 5
• Ensure continuation of guideline-directed medical therapy for CHF (ACE inhibitors/ARBs and beta-blockers) unless contraindicated 1, 4, 5
• Establish stable oral diuretic regimen if patient was receiving IV diuretics during hospitalization 4, 5
• Document antibiotic regimen with clear duration and monitoring parameters for cellulitis 1

Essential Components of SNF Transfer Communication

Comprehensive Clinical Information Required

The hospital must provide bidirectional written and verbal communication to the SNF including: 1

• Ejection fraction, NYHA functional class, type of HF, and recent echocardiogram results 1
• Weight trajectory during hospitalization with indication of volume status 1
• Current vital signs, laboratory values (BUN, creatinine, potassium, sodium, hematocrit) 1
• Physical assessment findings including edema, jugular venous pressure, and cellulitis characteristics 1
• Complete list of comorbid illnesses and DNR status 1

Specific Management Plans

• Detailed wound care instructions for cellulitis with frequency of dressing changes and monitoring parameters 1
• Daily weight monitoring protocol with specific thresholds for notifying provider (weight gain >2kg in 3 days) 5
• Oxygen requirements and parameters for titration 1, 4
• Mobility plan with walker, including physical therapy goals and fall precautions 1
• Dietary restrictions including sodium limitation to <5g/day and fluid restriction if applicable 5

Critical Monitoring Parameters for SNF Staff

Daily Assessments Required

• Daily weights at same time with same clothing after voiding 5
• Vital signs including blood pressure, heart rate, respiratory rate, and oxygen saturation 1, 4
• Assessment for signs of worsening CHF (increased dyspnea, orthopnea, peripheral edema) 5
• Cellulitis monitoring for expansion of erythema, increased warmth, drainage, or systemic signs of infection 1
• Fluid intake and output documentation 4, 5
• Daily electrolytes, BUN, and creatinine during diuretic therapy 4, 5

Medication Adherence Support

• SNF staff must implement strategies to address the patient's history of intermittent medication refusal 1, 5
• Medication administration should be directly observed given prior non-adherence 5
• Patient education should be reinforced regarding importance of medication compliance 5

Transition Planning from SNF to Home

Criteria for SNF Discharge to Home

The patient should remain in SNF until: 1

• Cellulitis has completely resolved or patient/caregiver can manage wound care independently 1
• CHF is stable on oral medication regimen without need for frequent adjustments 1, 5
• Functional status improves to allow safe performance of activities of daily living, either independently or with identified home support 1, 2
• Patient demonstrates consistent medication adherence and understanding of self-care requirements 5
• Home environment assessment confirms safety and availability of needed support services 1, 6

Post-SNF Discharge Planning

• Arrange follow-up with primary care provider within 7 days of SNF discharge 1
• Schedule cardiology follow-up within 2 weeks for CHF management 1
• Ensure home health services are in place if needed for continued wound care, medication management, or physical therapy 1, 7
• Provide comprehensive written discharge instructions covering medications, diet, activity level, daily weight monitoring, and symptoms requiring immediate medical attention 1, 5

Common Pitfalls to Avoid

Premature Direct-to-Home Discharge

• Do not discharge directly home given functional decline and need for walker assistance without adequate home support assessment 1, 2, 6
• Elderly patients with functional dependency, recent cognitive dysfunction, and multiple active medical issues are at high risk for adverse outcomes with premature discharge 2, 3
• The patient's DNR status does not indicate readiness for less intensive care—it reflects goals of care preferences, not medical stability 1

Inadequate Transition Communication

• Failure to provide comprehensive clinical information to SNF staff is a major cause of adverse events and readmissions 1, 7
• SNFs have higher patient-to-staff ratios and limited on-site provider availability, requiring detailed written care plans 1
• Verbal communication alone is insufficient—written documentation of all management plans is essential 1

Overlooking Social and Functional Factors

• The patient's ability to mobilize with walker around the ward does not equate to safety for independent living at home 2, 6
• Discharge planning must address practical aspects of daily living, not just formal health services 6
• Patient preference to return home must be balanced against objective safety assessment and availability of support 6