January 23, 2015 Discharge To Community The Best Outcome for our Patients The following information may or may not be appropriate to your clinical setting. Please review the information and determine the appropriateness of the content prior to sharing with your staff. Eligible for LMS Credit: Yes Rehab Culture: Increasing Discharge to Community Discharge to the community is the key performance indicator most associated with quality by our patients, families, clients and physicians. Discharge to community includes those patients who are discharged from the IRF to their home, assisted living or board and care, essentially locations that are not funded by Medicare and are community based. In addition to quality of the program, discharge to community can also impact the financial performance of the unit by decreasing truncated payments. If the patient is discharged to a SNF or acute medical floor prior to the Medicare average length of stay, the CMG payment is reduced. Typically, an increase in discharge to community equates to a decrease in truncation rate. 1. Setting the expectation that discharge to home is the goal of rehabilitation during the pre-admission communication with the patient and family/caregivers. Set the culture that going home is possible and should be the plan for example the patient should start getting dressed in their regular clothing as soon as practical upon admission Educate the patient/family/caregiver of the extensive pre-discharge training they will receive prior to going home so that the discharge will be safe and successful Complete a home evaluation early in the rehab stay to understand all necessary goals for patient s return home 2. Early and frequent involvement of the family or support system in the rehab program is essential. Family members should be engaged from day one to: Receive education in preparation for discharge Have opportunities to participate in care Provide information about the home environment and home safety Receive updates on progress made on a routine basis, not just weekly after conference, including all team members. Family communication cannot be left to just the Social Worker or Discharge Planner 3. Family/caregivers should be involved in team conference or family/caregiver conferences should be held routinely, not just by request. A call should be placed to the family 1-2 days prior to the conference to remind them of the meeting; give an approximate time and duration of the meeting *Encourage family to make a list of questions in advance *Encourage physician involvement some physicians are reluctant to do this, fearing it will require too much time, however, most who have done it will attest that it decreases the number of pages and side bar conversations that end up happening throughout the week with the family 4. Barriers to discharge should be identified by the first team conference. Prior to discussion, a team member should be assigned to ask the question What will it take to get him/her home?. The person assigned this task may be the Social Worker, Physician, PD or any other consistent attendee at the meeting. Answer this question in the barriers section of the team conference summary form Barriers need to be specific and address functional tasks or activities with specific interventions to address those barriers Address those interventions in the treatment plan as long-term goals 5. Use of a transitional apartment if available. Allows the patient to demonstrate independence and gain confidence to return home Allows the family/caregivers to feel confident that they can provide needed care to the patient at home 6. Routinely involve patients in home evaluations, community re-entry activities and therapeutic passes Participation in therapeutic activities outside the confines of the hospital establishes the expectation with the patient and family that the patient can be successful outside the constant oversight of hospital personnel. 7. Use tools available from RehabCare on Knect (attached) to assist patients/families/caregivers in preparing for discharge including: Discharge Checklist (patient specific) Home Assessment form 1 Page
My Discharge Checklist to Home Name: Date: How I Get Around I can move around on level and non-level surfaces on my own. I can get in and out of a car, or use public transportation without help. I have enough endurance and speed to get around in my community. I know how to access my community s resources. I use my assistive device without any help. My Walking or Wheelchair Equipment I can use any walking aid or wheelchair on my own. I have my equipment identified and readily available. I am safe while using my device(s) in my home. I know how to take care of my equipment, and I am able to provide routine maintenance. My Daily Routines I can move in and around my home by myself. I can feed myself. I can put my clothes on and take them off on my own. I can bathe myself without any help. I can use the toilet without help. I am able to move around in my bathroom without any difficult. I can prepare simple meals in my kitchen without any help. I communicate effectively. I know how to manage my money. I know how to access transportation or services in my community. I can move around in my community without help. I can call if I need help. My Safety I am aware of when to access medical assistance. I know how to access medical assistance. I use good judgment in making my decisions. My Memory I know how to manage my household and my medications. I can complete a task or activity safely. I know how to answer the phone, pay bills and get my mail. How I Communicate I can verbally communicate to have my needs met. I know how to use a telephone. I know how to access emergency services. I know how to get in touch with the facility staff if I have any complications after my discharge. I know how to use my communication devices, and they are labeled correctly. 1 Page
My Discharge Checklist to Home My Nutrition I know how to use my utensils. I know my appropriate diet level. I know how much I need to eat/drink to stay well nourished and hydrated. I know how to perform my facial exercises. I know my swallowing strategies. I can feed myself without help. My Medications I know the names of my medications. I know the MD who prescribed my medications. I know the amount of medications I take. I know the times of day to take my medications. I know where my daily record is of all my medications. My Doctor s Name and Telephone Number is: For My Discharge Home I know when I am going home and I know where I will be living. I have all the proper equipment I need to get around safely at home. I know how to use my community resources. I can demonstrate my home exercise program, how to manage my medications, and how to perform my daily tasks without help. Resources Family Members (Name & Telephone Number) Doctors (Name & Telephone Number) Appointments (Dates & Telephone Numbers) Other (Name & Telephone Number) 2 Page
Home Assessment Form Rehab Diagnosis: Date Completed: Discharge Date: OUTSIDE Driving Surface: Rough Smooth Walkway Location of Parking: Carport Garage Parking Lot Street Transfer To and From Car: Safe Independent Assist: Residence: House Mobile Home Apartment Board & Care Other: # of Floors Floor of Apartment Inside Stairs: Location: # Railing: Right Left Both None Entrance: Stairs # Railing: Right Left Both None Elevator Ramp Space Available for ramp, if indicated Flooring Type & Locations: INSIDE Note accessibility based on patient s abilities/limitations: BEDROOM ACCESSIBLE COMMENTS Bed (note type & side of approach) Closet/Dressers Space for Bedside Commode BATHROOM ACCESSIBLE COMMENTS Tub/Shower (note style) Sink Toilet Electric Outlets Addressograph: THE REHABCARE PROGRAM AT [HOST] HOME ASSESSMENT RehabCare 03.14 Page 1 of 3
Home Assessment Form KITCHEN ACCESSIBLE COMMENTS Stove Sink Refrigerator Freezer Cabinets/Cupboards Electric Outlets Countertops Dining Table MAIN LIVING ACCESSIBLE COMMENTS Furniture MISCELLANEOUS ACCESSIBLE COMMENTS Telephone Hallways Washer/Dryer Addressograph: THE REHABCARE PROGRAM AT [HOST] HOME ASSESSMENT RehabCare 03.14 Page 2 of 3
Home Assessment Form Equipment Recommendations: hospital bed raised toilet seat bathtub bench wheelchair shower chair 3 in 1 commode bedside commode grab bars: location: kitchen utility cart mirror for stove hand-held shower other: alternate seating/furniture Comments: Home Modifications Recommendations: Comments: ramp stair railings doors widened furniture arrangement furniture modifications kitchen bathroom bedroom main living area other Safety Recommendations: clear walkways extension cords stove throw rugs plumbing under sink telephone location and/or cords other Comments: Copy given to patient/family Yes No Other: Staff Signature/Title Date Staff Signature/Title Addressograph: Date THE REHABCARE PROGRAM AT [HOST] HOME ASSESSMENT RehabCare 03.14 Page 3 of 3