Download Clinical II Inservice

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.