Discharge Planning in the Acute Care Setting

1. Discharge Planning in the Acute Care Setting Sara Cordell February 16, 2011

2. Discharge Planning • “Development of discharge plan for follow-up services for a patient prior to leaving hospital with the aim of containing costs and improving patient outcomes” • Includes many disciplines: care coordinators, nurses, social workers, physicians, occupational therapists, physical therapists

3. Proper Discharge Planning • Effective communication • Collaboration with other disciplines • Thorough evaluation • Detection of red flags • Advocate for patient • Proper education • Follow through

4. Benefits • Maximizes patient’s potential • Decreases safety risk • Decreases readmission rate • Allocates resources appropriately • Decreases health care costs • Informs patients

5. Improper Discharge Planning • Lack of elements of proper discharge planning • Discharged prematurely • Discharged to inappropriate setting • Inadequate education or resources • Lack of insurance coverage

6. Consequences • Patient cannot reach potential • Risk for readmission • Increased health care costs • Decreased resources for other patients • Adverse events or conditions

7. Risks for Poor Discharge Outcomes • Over 80 years old • Inadequate support system • Multiple health problems (CHF, DM, ESRD) • History of depression • Moderate to severe functional impairment • Multiple hospitalizations in 6 months • Hospitalization in past 30 days • Patient rates health as fair or poor • History of non-compliance • Living alone (50% chance of early readmission) • Limited education (42% chance)

8. 4 Important Constructs • *Function and disability pre-admission and currently • Wants and needs of patient and family • Ability to participate in care • Life context

10. Reported Influential Factors • Diagnosis • Prognosis • Comorbidities • Cognition • Functional abilities • Ability to perform ADLs • Demographic characteristics • Insurance coverage

11. Reported Influential Factors • Level of pain • Financial resources • Prior use of services • Overall opinion of safety • Therapist experience • Input from other disciplines • Mathematical models, screenings or standardized tests??

13. What is most important factor? • Unsworth et al • Mobility • Ability to perform ADLs • Level of social support • Morrow-Howell and Proctor • Medical factors (pathology, level of dependency, cognitive state) • Jensen et al • Current and prior function • Patient’s interests and motivation

14. University of Michigan Hospital Study • 743 patients examined • Average hospital stay of 11 days • PT evaluated day 4 on average • Discharge locations: • Home without PT 44% • Home with home PT 26% • Subacute rehab/SNF 19% • Acute rehab 5.5% • Expired 2.5% • Home with outpatient PT 2% • Extended care facility without PT 1%

15. University of Michigan Hospital Study • Discharge plan matched PT recommendations 83% of the time • When PT recommendations ignored, patient 2.9 times more likely to be readmitted • Patients discharged to extended care facility without PT were 6.9 times more likely to be readmitted • Patients discharged to acute rehab less likely to be readmitted • 18% readmitted within 30 days • 43% over age of 60 discharged home reported unmet PT needs

16. Readmission Rate Based on Discharge Location

17. Odds of Readmission

18. Case Management • Study examined use in preventing readmission and/or institutionalization of elderly • Significantly more patients discharged home if in care management group • Discharge management significantly decreased risk of institutionalization • Number of readmissions from 15-90 days post discharge not significantly different • Suggest higher involvement in education and follow-up

19. Reengineered Discharge • RED is package of discharge services to decrease unsuccessful discharge • Decreased hospital utilization by 30% after discharge • Increased patient knowledge and understanding • Model includes: • Patient centered education • Comprehensive discharge planning • Post-discharge reinforcement • Pharmacist counseling and follow-up phone call

20. How accurate are recommendations of PTs? • 18% readmitted, but study does not highlight reason for readmission • Recommendations followed 83% of the time indicating worth • Experience does not effect discharge recommendations • PTs provide most information and offer the most insight about patient and his/her discharge status • Concluded physical therapist input extremely important in discharge planning process

21. Room for Improvement • Communication • Follow through • Thoroughly evaluate • Evidence supports collaborating with other disciplines • Many aspects from nursing/care coordinator perspective • Screenings? • Standardized tests? • Models?

22. References • Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending discharge placement from the acute care setting. Phys Ther. 2003; 83: 224-236. • Smith BA, Fields CJ, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are accutely ill. Phys Ther. 2010; 90: 693-703. • Steeman E, Moons P, Milisen K, et al. Implementation of discharge management for geriatric patients at risk for readmission or institutionalization. IntJounral for Quality in Health Care. 2006; 18: 352-358. • Minott, J. Reducing hospital readmissions. Academy Health. http://www.academyhealth.org/files/publications/Reducing_Hospital_Readmissions.pdf. • Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization. Annals of Internal Medicine. 2009; 150: 178-187. • Arbaje AI, Wolff JL, Yu Q, et al. Postdischarge environmental and socioeconomic factors and likelihood of early hospital readmission among commmunity dwelling Medicare beneficiaries. The Gerontologist. 2007; 48: 495-504.