DISCHARGE FROM ACUTE CARE

1. DISCHARGE FROM ACUTE CARE • Patient medically stable • Work up is complete • Patient safe to go home

2. QUALITY MEASURES • READMISSION TO HOSPITAL WITHIN 30 DAYS AFTER DISCHARGE • REEVALUATION IN E.R. WITHIN 30 DAYS AFTER DISCHARGE

3. REASONS FOR READMISSIONS • FALLS • DEHYDRATION • TAKING MEDICINES INCORRECTLY

4. LOS • 2006 • GOAL OF 5.75 DAYS • DISCHARGE PLANNING

5. ADMISSION • SOCIAL HISTORY • HOME SITUATION • HOW INDEPENDENT DOES THE PATIENT NEED TO BE WHEN THEY GO HOME?

6. HOME SITUATION • DO THEY LIVE • ALONE? • WITH FAMILY/ FRIENDS?

7. FAMILY / FRIENDS • DO THEY ASSIST IN CARE • DO THEY PROVIDE SUPERVISION • IS IT 24/7 • DURING DAY • DURING THE NIGHT

8. SAFE DISCHARGE HOME ALONE • INDEPENDENCE IN • HOUSEHOLD MOBILITY • TOILETING • MEAL PREP • USING PHONE IN EMERGENCY • TAKING MEDICINES

9. SERVICES IN THE HOME • MEDICARE AND SOME PRIVATE INSURANCES PROVIDE IN HOME SERVICES • P.T., O.T. , SPEECH THERAPY • 3 TIMES PER WEEK • NURSE TO MONITOR MEDICAL PROBLEMS • AID FOR BATHING, HYGIENE WHILE GETTING HOME HEALTH NURSING, P.T. OR SPEECH THERAPY

10. CARELINK • FOR LOW INCOME PATIENTS • 65 OR OLDER

11. CARE LINK • PROVIDES • AID SERVICE • UP TO 3 HOURS/DAY • 2-5 DAYS/WK. • MEALS ON WHEELS • 6 WEEKS WAIT

12. MOBILITY EVALUATION • P.T. EVALUATION • IS THE PATIENT AT RISK FOR FALLS? • LEVEL OF INDEPENDENCE IN MOBILITY • WOULD FURTHER THERAPY IMPROVE INDEPENDENCE & SAFETY? • WOULD EQUIPMENT IMPROVE INDEPENDENCE & SAFETY?

13. PHYSICAL THERAPY EVALUATION • ABILITY TO PARTICIPATE IN THERAPY • WHETHER PATIENT NEEDS • HOME HEALTH THERAPY • ACUTE INPATIENT REHAB • SUBACUTE INPATIENT REHAB

14. P.T. EVALUATION • BED MOBILITY • SUPINE TO SIT • SIT TO STAND • TRANSFERS • STANDING BALANCE • AMBULATION

15. FIM SCORES • INDEPENDENT - 7 • MODIFIED INDEPENDENT – 6 • NEEDS A.D. OR MORE TIME • SUPERVISION - 5 • MINIMAL ASSISTANCE - 4 • 25% ASSISTANCE NEEDED • MODERATE ASSISTANCE - 3 • 50% ASSISTANCE NEEDED • MAXIMAL ASSISTANCE - 2 • 75% ASSISTANCE NEEDED • TOTAL ASSISTANCE - 1

16. INDEPENDENCE IN SELF CARE • O.T. EVALUATION • INDEPENDENCE IN A.D.L.’S

17. O.T. EVALUATION • FEEDING • GROOMING • TOILETING • U.E.DRESSING • L.E.DRESSING • BATHING

18. O.T.EVALUATION • CAN THEY COOPERATE IN THERAPY DESPITE CONFUSION? • CAN THEY COOPERATE WITH BOTH O.T. AND P.T. DESPITE POOR ENDURANCE ? • WOULD ANY EQUIPMENT MAKE THEM SAFER OR MORE INDEPENDENT AT HOME?

19. FACTORS INTERFERING WITH P.T./O.T. EVALUATION • HYPOTENSION • ORTHOPEDIC/ NEUROSURGICAL PRECAUTIONS • CONFUSION • POOR ENDURANCE

20. OPTIONS FOR DISCHARGE • HOME • ALONE OR WITH FAMILY/FRIENDS • HOME HEALTH THERAPY • OUTPATIENT THERAPY

21. OPTIONS FOR DISCHARGE • ACUTE INPATIENT REHABILITATION • SUBACUTE INPATIENT REHABILITATION • SPECIALTY HOSPITAL • NURSING HOME

22. ACUTE INPATIENT REHABILITATION • 3 HOURS / DAY THERAPY • 5-6 DAYS / WEEK • MULTIDISCIPLINARY THERAPY • MEDICAL SUPERVISION 5-6 DAYS / WEEK

23. INSURANCE • MEDICARE • PRIVATE INSURANCE • MAY OR MAY NOT HAVE REHAB. BENEFIT • CHARITY IS SOMETIMES AN OPTION

24. ACUTE REHAB EVALUATION • CAN THEY TOLERATE BID OT AND PT IN ACUTE CARE? • CAN THEY COOPERATE AND PARTICIPATE IN THERAPY? • DO THEY NEED MORE THAN ONE TYPE OF THERAPY? • ARE THEY MEDICALLY STABLE? • IS THE WORK UP COMPLETE? • IS DISCHARGE HOME REALISTIC?

25. EVALUATION BY ACUTE REHABILIATION • SW FIND FAMILY / PT. PREFERENCE • REFERRAL MADE • FACILITY REVIEWS • PROGRESS NOTES • THERAPY NOTES • LAB & X-RAYS • LOOKS AT HOME SITUATION • POSSIBLE P.M.&R. CONSULT

26. REHABILITATION DIAGNOSIS • 75/25 RULE • SCI / TBI / CVA / AMPUTEE • NEURO./ HIP FX./ BURN/ R.A. • NON DIABETIC P.N/.MYOPATHY • DON’T COUNT OTHER FX.’S • CARDIAC/PULMONARY REHAB • DIABETIC P.N./OSTEOARTHRITIS

27. ACUTE REHABILITATION • MAY TAKE 1-2 DAYS TO GET PATIENT EVALUATED • HAVE INSURANCE APPROVED • THEN HAVE TO ARRANGE TRANSPORTATION TO FACILITY • VAN TRANSPORTATION MAY NOT BE AVAILABLE ON WEEKENDS

28. SUBACUTE INPATIENT REHABILIATION • HOSPITAL BASED RECUP. CARE • T.C.U. IN SKILLED NURSING FACILITY

29. SUBACUTE INPATIENT REHABILIATION • 1- 2.5 HOURS / DAY THERAPY • 3 TIMES PER WEEK • MEDICAL FOLLOWUP 3 DAYS WEEK • 1-3 TYPES OF THERAPY • DON’T HAVE TO HAVE POTENTIAL TO GO HOME

30. SUBACUTE INPATIENT REHABILITATION • COVERED BY MEDICARE • NOT OFTEN COVERED BY PRIVATE INSURANCE • NOT COVERED BY MEDICAID • NO CHARITY ADMISSIONS

31. SUBACUTE REHAB. EVALUATION • S.W. FINDS OUT PATIENT/ FAMILY PREFERENCE • FAMILY OFTEN WANTS TO VISIT FACILITIES FIRST • REFERRAL MADE TO FACILITY

32. SUBACUTE REHAB. EVALUATION • FACILITY REVIEWS • PROGRESS NOTES • THERAPY NOTES • INFORMATION ABOUT PATIENTS SKIN, NURSING CARE, AND INFECTIONS REQUIRING ISOLATION

33. SUBACUTE REHAB. EVALUATION • EVALUATION MAY TAKE 1-2 DAYS • FACILITY MAY COME TO SEE PATIENT • FACILITY MAY ACCEPT BUT NOT HAVE A BED • BEST FOR S.W. TO SEND REFERRALS TO MORE THAN ONE FACILITY

34. SPECIALTY HOSPITAL • FOR PATIENTS NEEDING CONTINUED ACUTE CARE • FOR • VENT WEANING • RENAL PROBLEMS • WOUND CARE • IV ANTIBIOTICS

35. SPECIALTY HOSPITAL • COVERED BY • MEDICARE • SOME PRIVATE INSURANCE • NOT BY MEDICAID • NO CHARITY ADMISSIONS

36. NURSING HOME • PATIENT UNABLE TO RETURN HOME • NOT A CANDIDATE FOR INPATIENT ACUTE, SUBACUTE REHAB. OR SPECIALTY HOSPITAL

37. NURSING HOME • COVERED BY MEDICAID • PRIVATE PAY • LONG TERM CARE INSURANCE MAY PAY A PART • NOT COVERED BY • MEDICARE • PRIVATE HEALTH INSURANCE

38. DISCHARGE HOME • COMPLICATED BY • HOME SITUATION • PATIENTS LEVEL OF INDEPENDENCE IN MOBILITY AND A.D.L.’S • INSURANCE COVERAGE

39. DISCHARGE HOME • PLAN FOR DISCHARGE BY KNOWING HOME SITUATION AS EARLY AS POSSIBLE • MOBILIZE PATIENT O.O.B. AS EARLY AS POSSIBLE • START THERAPY AS SOON AS FEASIBLE • WORK CLOSELY WITH S.W.