Image of male nurse pushing senior woman in a wheelchair in nursing facility

The finest rehab care in the world is only as good as the diligence therapists display before, during and after a resident’s stay. And it could make the difference between a successful transition to a lower level of care and a rehospitalization. Experts tell here what works.

Adopt a patient-centric approach. It’s easier than you think to lose your focus when it comes to rehabilitation.

“Remember it’s who we care for, not where we care for them that counts, and remaining ever-mindful of their needs can help prevent relapse or a return to the hospital,” says Mark Besch, vice president of clinical services for Aegis Therapies. Consider appointing rehab “care navigators” to serve as advocates who oversee the provision of services across the continuum.

Keep communication lines open. Caregivers from acute care to skilled nursing to home care must always stay in the conversation.

“We cannot leave any discharge instructions to chance,” says Kathleen Weissberg, education director for Select Rehabilitation. “In the past, information and best practices may not have been shared because individuals felt like they were in competition with each other. With penalties for the SNF looming as early as 2019, we all need to recognize that we’re in this together and need to share and collaborate for the best possible outcomes.”

A therapist could forget to tell a nurse when a patient experiences an adverse event such as dizziness or pain — something that could lead to a preventable yet more serious condition because timely interdepartmental communication failed, she adds. 

“The first step in decreasing rehospitalizations is to make sure there is a solid and trusting relationship between therapy companies or other care communities and physicians and nurse practitioners,” adds Kristy Brown, president and CEO of Centrex Rehab.

Rehab should never take place in a vacuum. Ward off potential issues by closely monitoring rehab’s impact on a patient’s overall medical status, says Holli Benthusen, regional director of business development and client relations, Select Medical Rehabilitation Services.

“It’s critical to educate therapists to ensure their patient’s medical status is tended to and cared for thoroughly and properly,” she says. Closely monitor blood pressure, respiration and overall response to mobility “because therapists are the ones challenging the patient to perform functional activities like bathing, walking or eating.”

Administrators should closely track outcomes. Evidence-based care has been shown to significantly reduce hospital readmission rates — an approach focused on practices that restore a patient’s ability to perform functions such as ambulating, bathing and feeding.

One such tool is the Modified Barthel Index, which helps track essential activities of daily living, according to Garry Pezzano, senior vice president of Clinical Practice for Genesis Rehab Services and Respiratory Health Services. 

Margaret Kopp, vice president of clinical services and quality management for Select Medical Rehabilitation Services, believes a universal outcomes measurement tool for SNFs is overdue. 

“We need a system for looking at functional outcomes that will better enable us to determine that patients are at a level that is safe for them to return to a lesser level of care,” she says. 

Discharge planning takes diligence before and after a resident’s stay. 

“Some facilities believe they don’t have a problem with the way they are managing hospital transfers,” says Weissberg. “But you cannot know without regularly tracking hospital transfer data, trending your data, and comparing your data to benchmarks.”

Follow up on the progress of your discharged patient with family members or other caregivers. Ensure doctor and lab appointments are honored and medications reconciled, Weissberg adds. 

When appropriate, hold your discharged patient accountable for promptly communicating troubling symptoms and adhering to self-medication precautions, add Besch and Pezzano. n

Mistakes to avoid

Closing the file after your patient is discharged. New rules could hold you accountable if rehospitalization is blamed on poor follow-through on medical and therapy guidelines.

Ignoring how your patient’s primary diagnosis and overall medical state are affected by rehab, and vice-versa.