Sara Cordell
February 16, 2011
“Development of discharge plan for follow
-
up
services for a patient prior to leaving hospital
with the aim of containing costs and
improving patient outcomes”
Includes many disciplines: care coordinators,
nurses, social workers, physicians,
occupational therapists, physical therapists
Effective communication
Collaboration with other disciplines
Thorough evaluation
Detection of red flags
Advocate for patient
Proper education
Follow through
Maximizes patient’s potential
Decreases safety risk
Decreases readmission rate
Allocates resources appropriately
Decreases health care costs
Informs patients
Lack of elements of proper discharge
planning
Discharged prematurely
Discharged to inappropriate setting
Inadequate education or resources
Lack of insurance coverage
Patient cannot reach potential
Risk for readmission
Increased health care costs
Decreased resources for other patients
Adverse events or conditions
Over 80 years old
Inadequate support system
Multiple health problems (CHF, DM, ESRD)
History of depression
Moderate to severe functional impairment
Multiple hospitalizations in 6 months
Hospitalization in past 30 days
Patient rates health as fair or poor
History of non
-
compliance
Living alone (50% chance of early readmission)
Limited education (42% chance)
*Function and disability pre
-
admission and
currently
Wants and needs of patient and family
Ability to participate in care
Life context
Diagnosis
Prognosis
Comorbidities
Cognition
Functional abilities
Ability to perform ADLs
Demographic characteristics
Insurance coverage
Level of pain
Financial resources
Prior use of services
Overall opinion of safety
Therapist experience
Input from other disciplines
Mathematical models, screenings or
standardized tests??
Unsworth
et al
◦
Mobility
◦
Ability to perform ADLs
◦
Level of social support
Morrow
-
Howell and Proctor
◦
Medical factors (pathology, level of dependency,
cognitive state)
Jensen et al
◦
Current and prior function
◦
Patient’s interests and motivation
743 patients examined
Average hospital stay of 11 days
PT evaluated day 4 on average
Discharge locations:
◦
Home without PT 44%
◦
Home with home PT 26%
◦
Subacute
rehab/SNF 19%
◦
Acute rehab 5.5%
◦
Expired 2.5%
◦
Home with outpatient PT 2%
◦
Extended care facility without PT 1%
Discharge plan matched PT recommendations
83% of the time
When PT recommendations ignored, patient
2.9 times more likely to be readmitted
Patients discharged to extended care facility
without PT were 6.9 times more likely to be
readmitted
Patients discharged to acute rehab less likely
to be readmitted
18% readmitted within 30 days
43% over age of 60 discharged home
reported unmet PT needs
Study examined use in preventing
readmission and/or institutionalization of
elderly
◦
Significantly more patients discharged home if in
care management group
◦
Discharge management significantly decreased risk
of institutionalization
◦
Number of readmissions from 15
-
90 days post
discharge not significantly different
◦
Suggest higher involvement in education and
follow
-
up
RED is package of discharge services to
decrease unsuccessful discharge
Decreased hospital utilization by 30% after
discharge
Increased patient knowledge and
understanding
Model includes:
◦
Patient centered education
◦
Comprehensive discharge planning
◦
Post
-
discharge reinforcement
◦
Pharmacist counseling and follow
-
up phone call
18% readmitted, but study does not highlight
reason for readmission
Recommendations followed 83% of the time
indicating worth
Experience does not effect discharge
recommendations
PTs provide most information and offer the
most insight about patient and his/her
discharge status
Concluded physical therapist input extremely
important in discharge planning process
Communication
Follow through
Thoroughly evaluate
Evidence supports collaborating with other
disciplines
Many aspects from nursing/care coordinator
perspective
Screenings?
Standardized tests?
Models?
Jette
DU, Grover L, Keck CP. A qualitative study of clinical decision
making in recommending discharge placement from the acute care
setting.
Phys
Ther
. 2003; 83: 224
-
236.
Smith BA, Fields CJ, Fernandez N. Physical therapists make accurate and
appropriate discharge recommendations for patients who are
accutely
ill.
Phys
Ther
. 2010; 90: 693
-
703.
Steeman
E, Moons P,
Milisen
K, et al. Implementation of discharge
management for geriatric patients at risk for readmission or
institutionalization.
Int
Jounral
for Quality in Health Care.
2006; 18: 352
-
358.
Minott
, J. Reducing hospital readmissions. Academy Health.
http://www.academyhealth.org/files/publications/Reducing_Hospital_Re
admissions.pdf.
Jack BW,
Chetty
VK, Anthony D, et al. A reengineered hospital discharge
program to decrease
rehospitalization
.
Annals of Internal Medicine.
2009; 150: 178
-
187.
Arbaje
AI, Wolff JL, Yu Q, et al.
Postdischarge
environmental and
socioeconomic factors and likelihood of early hospital readmission
among
commmunity
dwelling Medicare beneficiaries.
The Gerontologist
.
2007; 48: 495
-
504.
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