Shelly Mesure, MS, OTR/L
Many facilities use a checklist to assist with this process. “Have you considered the following … ” before officially determining a final discharge date. If you don't have this list, don't worry. It's pretty easy to develop. Many of the typical questions involve things such as, “Has rehab reached their maximum level of potential?” “Is there anything we can skill Medicare Part A under nursing?” etc.
Some facilities have policies, such as, “Don't have rehab discharge on Fridays.” But does this really extend the length-of-stay, or shorten it by several days?
I think to truly improve this process, you have to consider all factors — short-term vs. long-term discharge planning procedures, additional services (home health, restorative nursing programs), and flexibility of the resident and their discharging needs.
Let's start talking about short-term vs. long-term discharge determinations. When a resident is admitted to our facilities due to complex medical issues, we work tirelessly to improve her or his health and well-being. Unfortunately, not all residents are able to return to their prior level of functional status. However, with the help of the support available at home can they remain a short-term discharge plan?
When we tell someone they are no longer able to return home and must consider long-term nursing home placement, we have just significantly altered this person's life. This is one of the reasons that I believe CMS has included the discharge planning questions in Section Q of the MDS 3.0.
So, if a resident can remain to have a short-term discharge plan, now we begin our checklist of questions. Here's a sample of questions I always ask rehab:
1. If the patient were independent at home, and we're suggesting discharge at a supervision level, what additional rehab would be needed to return her or him to the independent status prior to discharge?
2. In addition to the functional mobility tasks they must perform inside the home, have we considered their ability to walk on uneven surfaces (such as a sidewalk) or manage a curb with their cane or walker?
3. Have we provided them with any training on how to stand up from the floor level? It's important for our social workers to provide the resident with information on the medical-alert systems, but what if they had a mild fall and actually cause an injury because of attempting to get up in an unsafe manner?
4. Nursing does a great job of explaining all of the medications we're sending someone home with, but has occupational therapy challenged the resident with medication management tasks? Can the resident distinguish between the red and orange pills that, other than color, look exactly the same?
There are so many of these types of questions, you just need to start thinking beyond “the box.” If you can begin to consider these options, it will only strengthen the final week(s) of treatment and provide excellent performance outcomes for all discharges.
In the meantime, you justified additional therapy needs, therefore, extending length-of-stay.
Shelly Mesure ("Measure"), MS, OTR/L, is the president and owner of A Mesured Solution Inc., a rehabilitation management consultancy with clients nationwide. A former corporate and program director for major long-term care providers, she is a much sought after speaker and writer on therapy and reimbursement issues.