More providers need how to use an interdisciplinary team approach to be more effective when managing transitions from the nursing home environment to a community living setting.
Additionally, successful transition from skilled rehabilitation involves adequate training of the patient and caregivers in the prescribed techniques and procedures for optimal functional performance; carryover of skills learned and/or achieved in therapy and demonstration of those skills over the course of the entire day/week on the nursing unit under indirect supervision. This is particularly effective when the discharge plan is questionable.
In order to facilitate a safe and effective discharge from rehabilitation as well as discharge planning, questioning is required by the interdisciplinary team to ensure all patient needs are met. Discharge planning questions should include:
* Why is the patient being discharged?
* Has the patient met his or her therapy goals or are there physiological or medical issues preventing participation and/or response to treatment?
* Has the patient met his or her medical goals?
* Have the therapist and the patient reviewed the therapy goals in the past two weeks?
* Has a home assessment been conducted if the patient is returning to home?
* Has the facility provided an opportunity while the patient is still in the facility and supervised to be as independent as possible?
* What is the patient able to do for himself or herself and what does the person still need help with?
* Who will be providing that assistance?
* Is the caregiver/family prepared/educated to provide the assistance?
* Have we provided the education?
* Have we observed firsthand the caregiver and patient together to see abilities/needs?
* Do we need to ask other team members to provide education?
* Have we asked the patient/caregiver/family what their needs are?
Professionals should work with the therapy staff in the skilled nursing facility to grow their discharge planning treatment programs. By following this process, patients will be discharged to an environment that has been assessed and adapted.
You can also make sure that therapy has comprehensively addressed all needs, the patient is successful, the families are happier, and clinical outcomes are positive with the clinically anticipated Medicare length of stay reflecting improvement.
Kris Mastrangelo, OTR, MBA, LNHA, is president and CEO of Harmony Healthcare International, a consultancy that provides onsite auditing of MDS and associated medical records
