Discharge Planning in Rehabilitation

Definition and Purpose

Discharge planning aims to reduce hospital length of stay, coordinate care, and ultimately improve patient outcomes by ensuring a safe transition between the acute care facility, rehabilitation, outpatient settings, primary care, and community 1
The goal is to optimize rehabilitation potential, ensure proper secondary prevention, and maintain continuity of care while meeting the discharge needs of the patient and family 2
It serves as a critical process to identify long-term needs and help organize provision of necessary services for patients transitioning from one care setting to another 3, 4

Create a patient-centered, culturally appropriate care plan that defines ongoing medical, functional, rehabilitation, cognitive, communication, and psychosocial needs 1
Conduct pre-discharge assessment of patient's physical needs, functional status, and mobility 5
Assess caregiver capacity and patient/family psychosocial needs that may impact recovery 5

The discharge planning process should involve a well-organized collaboration between health professionals, patients, families, and caregivers 1
The rehabilitation medicine team evaluates the patient and develops a rehabilitation plan 2
Discharge planners integrate the concerns and expectations of the interdisciplinary team with those of the patient and family 2

Perform home assessment to identify necessary modifications for accessibility and safety 1, 5
Arrange planned, goal-oriented home visits to identify potential barriers and assess readiness for discharge 5

Provide caregiver training specific to the ongoing needs of the individual patient 5
Ensure patients and caregivers understand home exercise programs and activity modifications 5
Teaching patients and families how to identify and deal with the nuances of their condition facilitates community reintegration and optimizes outcomes 2

Develop written discharge instructions addressing functional ability, safety considerations, and action plans for recovery 5
Create a post-discharge follow-up plan initiated by a designated team member 5
Establish clear communication channels with the next provider of care 5, 6

Reduced hospital length of stay and readmission rates for patients with medical conditions 3, 4
Greater caregiver preparedness for post-discharge care 1, 5
Improved functional outcomes and increased cost-effectiveness when organized home health care is implemented 2

Consider alternative methods of communication and support such as telephone visits, telehealth, or web-based support, particularly for patients in rural settings 3, 4

For patients too disabled to participate in or benefit from rehabilitation, hospital staff plays a crucial role in discharge decisions 2
Options include skilled nursing care to assess for future rehabilitation potential, skilled nursing care alone, palliative care, or hospice care 2