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!