Success Beyond Discharge

As skilled nursing facility providers and caregivers, we are privileged to experience many of the fruits of our patient’s progress during their stay, directly related to the services and care that we provide. We are able to share in the excitement and pride that accompanies progress towards a safe discharge to the next level of care after sustaining an often times life-altering injury or health-related episode. But what about life after discharge from our care? Are we confident that our patients and their caregivers are equipped to maintain their progress and successful outcomes, on their own?

The healthcare community, including the Centers for Medicare and Medicaid Services (CMS), emphasizes the importance of interdisciplinary, comprehensive discharge planning from the time of the patient’s admission. Recent literature suggests that the interdisciplinary team (IDT) is able to reduce hospital readmissions and facilitate successful outcomes beyond discharge through provision of high-quality discharge information, participation of the patient and caregiver in the discharge process and focus on increasing the patient and caregiver’s understanding of the discharge information (Hesselink et. al, 2014).  All skilled nursing providers play an important role in the interdisciplinary approach to discharge planning, and a collaborative partnership between therapy, facility staff, case managers, family, and the patient is paramount to success. The weight of the interdisciplinary team’s commitment to patient and caregiver preparation for the next level of care cannot be overlooked. Consider these key components of discharge planning throughout the patient’s stay:

  •  Upon admission:
    • From the time of admit, discharge plans should be considered. Goals should be developed and updated to ensure preparedness for the setting, level of assistance, and needs anticipated at discharge.
  • Throughout the episode of care:
    • Consider a system to ensure all staff are aware of the patient’s personal goals. Implement ongoing patient/caregiver education for health literacy, functional targets, and training to allow ample time for questions, problem solving, and repetition prior to time of discharge.
  • At time of discharge:
    • Provide clear, comprehensive, and accurate information regarding the patient’s discharge level of function, recommendations for equipment or follow-up care, and level of assistance or supervision for daily tasks. Enable the patient and caregiver’s understanding of skilled staff recommendations.

Reliant has created proprietary resources to guide clinicians through comprehensive, effective discharge planning. These resources can also facilitate education, trainings, and increased opportunity for IDT discussion.  Check out Reliant’s Discharge from Therapy to Community Packet and Discharge from Therapy to Nursing Packet to ensure that your patients and caregivers are properly prepared for the next level of care.

With effective discharge planning that occurs throughout the patient’s episode of care, we can facilitate carryover of learned strategies, patient and caregiver confidence, reduced risk of rehospitalization and successful outcomes beyond discharge from therapy.  Reliant is proud to partner with you to confidently guide our patients, caregivers, and staff through discharge planning that will lead to patient success beyond discharge!

References

Hesselink, G., Zegers, M., Vernooij-Dassen, M., Barach, P., Kalkman, C., Flink, M., Öhlen, G., Olsson, M., Bergenbrant, S., Orrego, C., Suñol, R., Toccafondi, G., Venneri, F., Dudzik-Urbaniak, E., Kutryba, B., Schoonhoven, L., Wollersheim, H., & European HANDOVER Research Collaborative (2014). Improving patient discharge and reducing hospital readmissions by using Intervention Mapping. BMC health services research14, 389. https://doi.org/10.1186/1472-6963-14-389

Clinicians Who Inspire: September 2021 Melissa Huggins

Through the Clinicians Who Inspire series, we continue to share motivation, creativity, and inspiration from clinicians in the field. This month we spoke with Melissa Huggins, Champion Level II Therapist, PTA, and Director of Rehabilitation at Panora Specialty Care in Iowa.  Melissa states that dealing with the effects of COVID-19 really forced her to think outside the box.  She mentioned the need for creativity in therapy interventions to help encourage participation in sessions.  Melissa and her team like to use Reliant resources like A Year of Wellness to help generate creative ideas.  One of Melissa’s favorite activities has been card making with patients during therapy.  The patients worked on their individualized therapy goals in conjunction with making cards for other residents who weren’t getting as much interaction.  A lot of the residents knew of others who might benefit from a little “pick-me-up” card, but if not, the therapy staff assisted in making those connections.  As part of their therapy intervention, the patients were often able to deliver the cards to their resident friends in person.  Melissa reports that these cards made everyone, from the therapy staff to the residents, very happy!  These interactions helped residents who were spending more time in their rooms to socialize and, in some cases, even leave their rooms to connect with other residents.  Melissa also reports that pictures of residents in therapy sessions being featured on social media is seen as a privilege.  One resident even told her, “You’re going to make me a star!”  Not only are your residents STARS to us, Melissa, but you are also as is the entire team at Panora Specialty Care!

Clinicians Who Inspire: August 2021 Shannon Rasmussen

Through the Clinicians Who Inspire series, we continue to share motivation, creativity, and inspiration from clinicians in the field. This month we spoke with Shannon Rasmussen, Champion Level II Therapist, and SLP at Pecan Tree Rehabilitation & Healthcare in Texas. Shannon states that working through the pandemic was the most trying time of her SLP career.  What kept her encouraged during those times is the advice she now gives other clinicians, “remember why you became a therapist.” Shannon stresses the importance of staying focused on remembering that we are in our field of work to help others. This focus is what motivated her to use her vocation to provide a positive, meaningful impact during the pandemic. When social isolation became a reality in her facility, Shannon decided to tackle a very real consequence of isolation- weight loss. She met with the dietary manager, and together they initiated a snack cart, filled with a variety of the residents’ favorite snacks. This cart would make its rounds at the facility and provide a real pick-me-up (and additional calories) to the residents spending increased time in their rooms. As in many facilities, another area of concern was the loss of communal meals. Shannon recognized that residents spending increased time in bed could negatively impact their cognitive and communication skills. She worked with the IDT to ensure residents were up and enjoying mealtimes. She even facilitated roommates enjoying socially distanced meals together while seated and facing each other to promote mealtime conversations and socialization. These seemingly straightforward strategies are just a couple of examples of Shannon and her IDT communicating, brainstorming, and working together to bring back some sense of normalcy during demanding times and a reminder to us to focus on our calling to provide patient-centered care. Thank you, Shannon, and team, for being clinicians who inspire each other, your patients, and all of your therapy peers! Keep up the amazing work you do each and every day!

Condensed Version:

Through the Clinicians Who Inspire series, we continue to share motivation, creativity, and inspiration from clinicians in the field. This month we spoke with Shannon Rasmussen, Champion Level II Therapist, and SLP at Pecan Tree Rehabilitation & Healthcare in Texas.  What kept her encouraged during trying times is the advice she now gives other clinicians, “remember why you became a therapist.”  When social isolation became a reality in her facility, Shannon decided to tackle a very real consequence of isolation- weight loss. Together with the dietary manager, they initiated a snack cart, filled with a variety of the residents’ favorite snacks. Another area of concern was the loss of communal meals. She facilitated roommates enjoying socially distanced meals together while seated and facing each other to promote mealtime conversations. These are just some examples of Shannon and her IDT working together to bring back some sense of normalcy during demanding times and a reminder to us to focus on our calling to provide patient-centered care. Thank you, Shannon, and team, for being clinicians who inspire each other, your patients, and all of your therapy peers! Keep up the amazing work you do each and every day! #CareMatters

Clinicians Who Inspire: July 2021 Danielle Grove

Through the Clinicians Who Inspire series, we continue to share motivation, creativity, and inspiration from clinicians in the field. This month we spoke with Danielle Grove, Mentor Therapist, COTA and Director of Rehab at University Park Nursing and Rehab in Iowa. Danielle credits her facility’s ability to maintain positive morale throughout the pandemic to continual communication with an interdisciplinary team approach. She shared the impact of therapy education and training with nursing staff on repositioning, swallowing, and ADL completion; allowing continual care and success even when restrictions were put in place to mitigate risks of transmission. “Without all of us working together, we wouldn’t be able to come together to be successful and positive for our patients”. Danielle also shared her team’s focus on promoting positivity throughout their building and community with patient-centered groups and celebrations. She recommends use of Reliant’s “A Year of Wellness” program, collaboration with Activities and Marketing departments within the facility, and collaboration with patients to identify fun ideas and opportunities to gather for a therapeutic activity that may also serve as a bright spot in your patients’ day. Through Danielle and her team’s efforts, they’ve seen a change in not only their building’s morale, but also their reputation in the community. Thank you, Danielle and team, for being clinicians who inspire each other, your patients, and all of your therapy peers! Keep up the amazing work you do each and every day!