Is Your Discharge Planning Up To Snuff?
For temporary SNF patients, we all know that discharge planning should begin on the day of admission as you discuss discharge goals with the resident and/or the resident’s representative, but what happens after that initial plan?
While it is imperative that the Interdisciplinary Team works together with the resident in the discharge planning process, a successful discharge of a rehab patient will rely heavily on the skill and effective communication of your therapy team as well. Lack of proper planning, quality documentation, and effective communication on the part of your rehab team could lead to failure in regard to your discharge goal setting, and a possible hospital readmission.
Be sure that your therapy team is not overlooking these important questions:
Did therapy meet short-term and long-term goals and return the resident back to baseline?
Was a Functional Maintenance Program (FMP) or restorative program established with caregivers? And is the FMP/Restorative program available for easy access by staff?
If a home discharge is planned, did therapy complete a home assessment?
Were environmental modifications completed?
Is the appropriate equipment ordered for delivery upon discharge?
Have caregivers been educated on modifications?
Has a home exercise program been developed and taught to the patient with return demonstration?
Have home health or outpatient orders been written and referrals been made?
Do family/caregivers demonstrate understanding of the patient’s needs and are they able to provide for those needs?
Skilled-nursing facility teams often feel pressure regarding length of stay and prompt discharge. Do not let these pressures interfere with safe discharge planning.
If you need help to rest assured that your team has the support they need, let us know. We offer a clear process for discharge and the tools therapists need for clear and concise communication and proper documentation of the plan.
Written by: Elizabeth Johnson, PT, CDP, RAC-CT
