Is your patient ready to go home?

Comprehensive discharge planning has become a key component of care planning in long term care settings as increased scrutiny and pending financial sanctions loom for both hospital and nursing home health care providers. How do we ensure that the patients we serve are ready to return home safely and at their highest level of independence?

The Pathway for a Safe Return Home

Functional Pathways has developed a comprehensive interdisciplinary discharge planning tool to ensure each patient has achieved the functional capacity and skills necessary for a safe discharge. Whether the patient will remain in long term care or be discharged to a lesser level of care, the discharge planning process is crucial in preventing re-hospitalization and missed opportunities to assist the patient in reaching maximum functional independence.

An Interdisciplinary Approach

Effective discharge planning requires an interdisciplinary team approach. All members of the care plan team must be involved in setting goals for potential discharge of the patient on the day of admission.

• What are the patient’s goals?
• Where do they want to live?
• What is the realistic potential for return to home?
• What was the prior level of function?
• Are the patient’s immediate family/caregivers part of the goal setting process?

Therapy Services

Communication with the care plan team is crucial in developing and a safe and effective discharge plan. Skilled therapy services can improve a patient’s ability to return to prior functional levels and promote a safe discharge home. When establishing discharge readiness from therapy services we must consider the following.

• What is the discharge setting? (home, ALF, SNF)
• Has the potential discharge environment been assessed by therapy? (home evaluation)
• Have all long and short term therapy goals been met? (goals revised, if needed)
• Has the patient stopped making functional gains?
• Has caregiver and patient training been completed?
• Has the interdisciplinary team discussed the patient’s status and come to an agreement regarding the discharge plan?

Preventing Re-Hospitalization

Premature discharge as a result of poor discharge planning can lead to significant incidences of re-hospitalization for patients in the long term care setting. As the industry sees more and more acute admissions, patients will have an expectation of shorter stays and in returning home.

It is vital to assist them in maximizing functional performance in everyday living skills, mobility and safety prior to returning home to decrease the potential of falls and recurring medical problems that could have been reduced with comprehensive care and interdisciplinary discharge planning. Often, ongoing communication and education is required to involve our patients in the recovery process and helping them to establish realistic goals and realistic time frames for safe