How to Make Verbal Order for Physical Therapy Discharged and Have Physical Therapy Again

• Journal List
• Phys Ther
• PMC2867215

Phys Ther. 2010 May; 90(5): 693–703.

Physical Therapists Make Authentic and Appropriate Discharge Recommendations for Patients Who Are Acutely Ill

Beth A. Smith

B.A. Smith, PT, DPT, PhD, is Postdoctoral Boyfriend, Balance Disorders Laboratory, Departments of Neurology and Behavioral Neuroscience, Oregon Health and Scientific discipline Academy, Portland, Oregon. During the data drove for this project, she was a PhD candidate in the Developmental Neuromotor Control Laboratory, School of Kinesiology, University of Michigan, and a per diem staff member, Sectionalisation of Physical Therapy, University of Michigan Hospital, Ann Arbor, Michigan. Institutional mailing address: NSI, OHSU Due west Campus, 505 NW 185th Ave, Beaverton, OR 97006 (USA).

Christina J. Fields

C.J. Fields, PT, MPT, is Physical Therapy Clinical Specialist, Cardiovascular Team, University of Michigan Infirmary.

Natalia Fernandez

North. Fernandez, PT, Master of Health Science (Physical Therapy), is Staff Physical Therapist, Cardiovascular Team, Academy of Michigan Hospital.

Received 2009 May 22; Accustomed 2010 Jan 3.

Abstract

Background

Acute care concrete therapists contribute to the complex process of patient discharge planning. As physical therapists are experts at evaluating functional abilities and are able to comprise various other factors relevant to discharge planning, it was expected that physical therapists' recommendations of patient discharge location would be both accurate and appropriate.

Objective

This study adamant how often the therapists' recommendations for patient discharge location and services were implemented, representing the accuracy of the recommendations. The touch of unimplemented recommendations on readmission rate was examined, reflecting the appropriateness of the recommendations.

Pattern

This retrospective study included the discharge recommendations of 40 acute care physical therapists for 762 patients in a large academic medical middle. The frequency of mismatch between the concrete therapist's recommendation and the patient'southward actual discharge location and services was calculated. The mismatch variable had 3 levels: friction match, mismatch with services defective, or mismatch with different services. Regression analysis was used to examination whether mismatch status, patient historic period, length of admission, or discharge location predicted patient readmittance.

Results

Overall, physical therapists' discharge recommendations were implemented 83% of the time. Patients were 2.9 times more than probable to be readmitted when the therapist's discharge recommendation was not implemented and recommended follow-upward services were lacking (mismatch with services lacking) compared with patients with a friction match.

Limitations

This study was express to one facility. Limited information nearly the patients was nerveless, and information on patient readmission to other facilities were not collected.

Conclusions

This study supports the function of physical therapists in discharge planning in the astute care setting. Concrete therapists demonstrated the ability to brand authentic and appropriate discharge recommendations for patients who are acutely ill.

Discharge planning is the evolution of a discharge plan for follow-up services for a patient prior to leaving the infirmary, with the aim of containing costs and improving patient outcomes.¹ Discharge planning is a complex process, and many health intendance disciplines may contribute to the plan, including formal discharge planning coordinators, nurses, social workers, physical therapists, occupational therapists, and physicians. Reviews of discharge planning processes showed that they consistently involve the assessment of many factors, including cerebral, physical and social/financial status, environmental concerns, and access to formal and breezy care.^{two , 3}

In an effort to assess these many factors, formal discharge planning in the U.s. often is good every bit a collaborative, multidisciplinary effort led past a case managing director, particularly for patients identified equally having an increased run a risk for poor outcomes.^{4 , 5} Although the shift toward collaborative discharge planning has improved patient outcomes, there remains room for further improvement. A report by Mamon and colleagues⁶ showed that multidisciplinary discharge planning efforts led by formal case managers appeared to be significantly more effective in arranging home nursing care and rehabilitation services than informal discharge planning; notwithstanding, patients nonetheless oftentimes reported these and other needs were unmet after discharge. The study did not examine how the discharge planning process failed to accurately identify or meet the needs of the patients, just as many health care professionals participate in the multifactorial process, the final decision on discharge placement may not take into consideration each professional's recommendation. Important information from ane discipline may exist overlooked or excluded from the last discharge plan, leading to failure of the plan.

Poor belch planning and the failure to provide necessary services may have an touch on at several levels: failure of the patient to reach optimal health and functional condition, increased cost to the infirmary and decreased resource availability to others due to increased length of stay and readmission, or possible adverse events or weather condition causing harm to the patient.⁷ In an try to better understand failure of the program, several factors have been associated with poor postdischarge outcomes: aged lxxx years and older; inadequate back up system; multiple, active, chronic health problems; history of depression; moderate to severe functional impairment; multiple hospitalizations during the prior 6 months; hospitalization within the past thirty days; fair or poor self-rating of health; or history of nonadherence to the therapeutic regimen.⁷

It is clear from the large number and broad nature of factors associated with poor discharge outcomes that belch planning is a circuitous procedure requiring the assessment and absorption of multiple factors. Boosted evidence of discharge planning as a complex procedure is the lack of use of standardized quantitative measures to decide belch recommendations. Despite the validation of measures such as the Berg Rest Scale to predict discharge disposition,⁸ concrete therapists and hospitals do not rely solely on standardized tests in regard to belch planning.^{9 , 10} Standardized screening forms are ofttimes used to place patients at high risk of poor outcomes in society to initiate the formal multidisciplinary belch planning process, but they are not used to make the decision on discharge location and services.^{3 , 5 , 6 , 11}

The need for comprehensive assessment of functional condition is i factor in discharge planning that is directly related to the practice of physical therapy. I written report quantified change in functional status, reporting that 35% of patients aged 70 years and older showed a decline in activities of daily living function between hospital admission and discharge.¹² Patients experiencing a reject in functional status while in the infirmary may no longer be able to function adequately in the environment they lived in prior to admission, and are less likely to recover baseline function and health condition.¹³ There is an association between decreased functional condition and transfers to and from astute care settings.¹⁴ There besides is an association between decreased functional status and complicated posthospital care transitions.¹⁵

The studies described in a higher place show that level of functional ability is related to discharge location; however, other studies demonstrate that the human relationship, consistent with the theme of belch planning, is complex. Although patients returning home had a higher level of role than those who were discharged elsewhere, some patients who were significantly impaired returned home with family unit support. Patients who had family support merely were discharged to facilities were the most impaired.⁸ Additionally, researchers studying the result of functional level on length of hospital admission establish that patients with a higher level of function demonstrated a shorter length of stay than boilerplate, merely patients with a low level of office who were discharged to a supportive environs likewise had a shorter-than-average length of stay.¹⁶ These findings highlight the circuitous relationship between functional ability and discharge needs and farther support physical therapist evaluation of functional abilities, assistance required for prophylactic, and recommendations for discharge location based on what the patient requires and what is available to them.

Physical therapists in the acute care setting play an important role in the multidisciplinary belch planning procedure. "Discharge to the appropriate level of intendance" oft is a goal in acute care physical therapy,¹⁷ and therapists routinely make recommendations regarding discharge placement and any continuing therapy services for patients. Due to short average lengths of admission in acute care, patients often need connected physical therapy services afterwards leaving acute care, and therapists may recommend that continued services accept place in the abode, a skilled nursing facility (SNF), a rehabilitation center, or an outpatient setting.¹⁸

Although creating a discharge plan is a multidisciplinary process, physical therapists practicing in astute intendance are in a unique position to assess the discharge needs of a patient. This is well described within the scope of practice in the Guide to Physical Therapist Practise: "The plan of care identifies anticipated goals and expected outcomes, taking into consideration the expectations of the patient/client and appropriate others…. The plan of care includes the anticipated discharge plans. In consultation with appropriate individuals, the physical therapist plans for belch and provides for appropriate follow-upward or referral."^xix(p46) Furthermore, physical therapists are wellness care professionals who diagnose and treat individuals of all ages who accept medical bug or other health-related conditions that limit their ability to move and perform functional activities in their daily lives,^xix and the cess of functional abilities is a particularly important and complex aspect in determining belch needs.

Having established that physical therapists are well qualified to participate in the complex discharge planning process, how do they come to a decision on a discharge recommendation? According to a qualitative study past Jette et al,^ix physical therapists appeared to use a patient's level of functioning and disability as the core dimension in their initial decision-making process. In general, they were guided by 4 constructs when making a belch recommendation: patients' functioning and disability, patients' wants and needs, patients' ability to participate in care, and patients' life context. The therapists gathered and integrated data from multiple constructs before making their discharge recommendation, showing consideration of what the patients required and what was available in their environment.^ix

Building upon previous descriptions of the complexities of the decision-making process and the idea that concrete therapists are uniquely suited to contribute useful insight through their evaluation and assessment skills, nosotros wanted to validate the participation of astute care physical therapists in the discharge planning process. Considering we hypothesized that therapists are able to successfully contain all of the various factors involved in the belch planning process and that in that location is value placed on the therapist'due south recommendation by the last belch plan conclusion maker, we anticipated that the therapist'southward discharge recommendations for patients in the acute care setting would friction match the patient'southward actual discharge location and services a majority of the time. Furthermore, supporting the thought that therapists are appropriate in their recommendations, we expected an increased likelihood of infirmary readmissions when recommendations were not implemented.

Method

The University of Michigan Hospital is a 700-bed acute care teaching hospital. Our facility is a level 1 trauma center offer and receiving helicopter transfers for patients from Michigan and its surrounding states who are in disquisitional and complex situations; many of our patients are transferred from outside hospitals for ongoing care.

Discharge Planning Process

The discharge planning process in our facility occurs in a fairly, but not completely, standardized fashion. The initial parts of the process are standard; practice management coordinators utilise a screening form based on the factors associated with poor discharge outcomes to screen all admitted patients and identify those who are at increased risk for poor discharge outcomes. Patients who are not identified equally high risk by the screening process take belch planning washed by their staff nurse, unless formal discharge planning is later requested. For patients who are identified as high risk, formal discharge planning is initiated, with practice management coordinators taking the lead part in the discharge planning process. They read the documentation on belch recommendations from the physical therapist evaluation and any subsequent physical therapist documentation and incorporate information technology into a multidisciplinary discharge planning process, including whatsoever documentation they read from the medical/surgical squad, unit of measurement nurses, and, when consulted, occupational therapists and social workers. In this bones process, the coordinator may or may not seek additional data from other members of the health care team. If a consensus has been identified, the coordinator proceeds to adapt insurance benefits and necessary services. If in that location is not a consensus, the coordinator will elicit boosted data from the other members of the health care team, usually using the hospital alphanumeric paging and telephone systems. A lack of consensus tin can occur, for case, if the patient's preferences change or if insurance benefits are not bachelor.

Physical therapist involvement in the discharge planning process starts when the medical/surgical squad sends an electronic consult to the Division of Physical Therapy through our online medical charting system. The therapist does an initial evaluation, with the exact procedures varying according to the ability of the patient to participate. The overall process is best described in the Guide to Physical Therapist Practise:

[Concrete therapists] engage in an examination process that includes taking the patient/client history, conducting a systems review, and performing tests and measures to identify potential and existing problems. To establish diagnoses, prognoses, and plans of care, physical therapists perform evaluations, synthesizing the test data and determining whether the problems to be addressed are within the scope of concrete therapist practice. Based on their judgments virtually diagnoses and prognoses and based on patient/client goals, physical therapists provide interventions (the interactions and procedures used in managing and instructing patients/clients), acquit reexaminations, modify interventions as necessary to accomplish anticipated goals and expected outcomes, and develop and implement discharge plans.^{nineteen(p21)}

The physical therapist documents his or her evaluation in the computerized patient medical record. At the meridian of every therapist evaluation and any subsequent documentation, information is highlighted that is especially relevant to discharge recommendations, specifically therapist recommendations for discharge location, the amount of assist required for patient safe, necessary assistive devices, and the need for ongoing physical therapy and the appropriate setting. This information is consistently provided by therapists, regardless of whether or not patients are receiving formal belch planning. Follow-upwards physical therapy treatments are provided equally advisable throughout the patient's astute intendance stay, and discharge recommendations are updated and documented each time a therapist works with the patient.

Although all physical therapist recommendations are consistently documented in the medical record in a standard manner, the remaining discharge procedure varies in how communication is exchanged. Across the basic belch planning process, some service areas of the hospital follow boosted procedures that increment in-person communication betwixt health care providers. Three of the services concur additional daily or weekly "discharge rounds" interdisciplinary meetings, attended by the resident medico, practice management coordinator, occupational therapist, physical therapist, and social worker. In addition, some coordinators work with 1 or 2 specific services and make information technology a point to meet in person with the therapists, whereas other coordinators float among services and do not do then.

Data Collection

To bear our retrospective study of the outcomes of the belch planning procedure, nosotros obtained University of Michigan Privacy Board approval for waiver of informed consent to access patient medical records and institutional review board approval for the use of concrete therapists as human participants. We accessed the medical records of all patients who received a physical therapist evaluation during our study menses. Nosotros besides collected information about career history from consenting therapists to further describe therapist do at our facility.

We created a secure database and separated identifying information about patients and therapists from de-identified, coded data collection forms. We selected one week (Dominicus–Saturday) in each flavour of the preceding year. The weeks were in December 2007 and March, June, and September 2008 and did non include whatever holidays.

Two enquiry assistants were trained, using case studies, to access medical records and find the relevant data and enter it into the database. Information was collected primarily from physical therapist evaluations and treatment notes, physician discharge notes, and practice management coordinator evaluations and notes. Occasionally, data were constitute in emergency department documentation, physician admitting history and physical documents, social work notes, nursing notes, and outpatient or rehabilitation facility documentation from our wellness system. Any questions related to information collection were resolved by consensus of the three primary investigators (B.A.S., C.J.F, and Northward.F.).

Variables and Inclusion Criteria

Nosotros identified 51 physical therapists who were working in acute intendance during our selected weeks. Forty out of the possible 51 therapists consented to participate in our study. The 11 therapists who were not included were those we could not contact, who were no longer employed at the academy, or who were temporary staff who did not evaluate patients during the 4 weeks we analyzed. 1 of the 3 master investigators discussed the study with each therapist before the informed consent course was signed. Later on consent, participating therapists were asked to provide the following groundwork data: full months of practise equally an acute care concrete therapist, full months and setting of other, nonacute care concrete therapist experience, and total months of exercise every bit an acute care physical therapist at Academy of Michigan Infirmary.

We used hospital billing records to identify that 780 patients received a physical therapist evaluation during our specified 4 1-week periods, and we included all of them in our report. Nosotros specified the following operational definitions and collected the following data from patient medical records:

• Age of patient, in years.

• Patient's primary service at discharge—service squad of attending physician at the fourth dimension of discharge, listed by abbreviation lawmaking.

• Date of admission, in MM/DD/YYYY format.

• Date of discharge, in MM/DD/YYYY format.

• Appointment of physical therapy evaluation, in MM/DD/YYYY format.

• Discharge location—the physical location the patient was sent to at the finish of the hospital access, coded as home without physical therapy, home with outpatient therapy, home with dwelling therapist, subacute rehabilitation/SNF, acute rehabilitation, extended intendance facility without therapy, or expired.

• Physical therapist at discharge—physical therapist identifier lawmaking of the therapist who documented the final belch recommendation.

• Physical therapist discharge recommendation—the discharge location and services that were adamant past the therapist equally necessary to promote patient rubber and whatsoever recovery, as based on the patient's current level of function and bachelor resources at discharge, coded as abode without concrete therapy, home with outpatient therapy, home with home therapist, subacute rehabilitation/SNF, astute rehabilitation, or extended intendance facility without therapy.

• Match—when the bodily discharge location and services were the same as the discharge recommendation in the terminal therapist documentation.

• Mismatch—when the actual belch location or services were not the same equally the discharge recommendation in the concluding therapist documentation.

  • ∘ Mismatch with services defective—the patient did non receive follow-upward services when a home therapist was recommended.

  • ∘ Mismatch with different services than recommended or actress services—the patient received home physical therapy instead of recommended outpatient therapy or the patient received home therapy when no follow-up therapy was recommended.

• Reason for mismatch, categorized as:

  • ∘ Patient refusal of placement—the therapist recommended placement or services, and the patient or his or her legal representative declined,

  • ∘ Insurance problems—the therapist recommended placement or services, and the patient did not receive them due to lack of insurance or insurance denial of services,

  • ∘ Medical complexity of the patient precludes placement—the patient is on a ventilator or receiving enteral/parental feedings, for example, or

  • ∘ Other—any other reason.

• Readmission—if the patient was admitted to our astute intendance facility within thirty days of discharge, a time period consistent with similar studies.^{11 , xx}

Data Analysis

We used Microsoft Excel software (Microsoft Office 2007)^* for database formation and SPSS software (versions 16.0 and 17.0) ^† for statistical analyses. We used descriptive statistics to summarize physical therapist and patient characteristics. We calculated the frequency of occurrence of patient discharge locations, mismatch, and readmission. Patients who expired were included in demographic and descriptive information only excluded from statistical analyses of mismatches or readmission. We used a general linear modeling technique, explained below, to decide which variables were associated with an increased adventure of readmission. An blastoff level of .05 was used for all hypothesis testing.

We did logistic regression analysis using generalized estimating equations to command for correlation of the outcomes by physical therapy and to predict the probability that a patient would be readmitted. The predictor variables we included in the model were mismatch status, patient age, length of admission, and discharge location. These are all of the variables nosotros collected that could have had an effect on readmission. Patient age and length of admission were complanate from continuous variables into categories to let for more than meaningful analysis. Historic period was categorized equally ≤35 years, 36 to 55 years, 56 to seventy years, 71 to 84 years, and ≥85 years. Length of admission was categorized as less than 2 days, two to iv days, five to 7 days, 8 to 10 days, 11 to 14 days, and ≥15 days. Mismatch status and belch location were categorized as previously defined.

Nosotros used this analytic approach rather than the more mutual method of linear regression for 2 reasons. First, our response variable (readmission) is a dichotomous event. Second, it allowed us to control for the fact that each physical therapist made discharge recommendations for multiple patients and outcomes for a given therapist were not contained.^{21 , 22} Preliminary models tested for correlation of outcomes past physical therapy, only the observed correlation was non pregnant. The reported results specified an contained correlation structure.

Results

Patient Demographics

Of the 780 patients nosotros identified as having received physical therapist evaluations in the specified 4 weeks, we successfully collected information from the medical records of 762 patients. 18 patients were excluded because their discharge location or the therapist recommendation could not be determined. This situation occurred when data was missing from the medical record or clerical errors led to an inability to locate the patient's medical tape. Of the 762 patients from whom we collected information, 743 were eventually discharged from acute care, and 19 expired. Patients tended to be older adults who were distributed across medical (48%), surgical (27%), neurology (seven%) and trauma/orthopedic (18%) services. Although the ranges were wide, the patients had an average infirmary admission of 11 days and were evaluated by a physical therapist around twenty-four hour period iv of their admission (Tab. one). The discharge locations of the patients from whom we collected data were every bit follows: dwelling house without physical therapy (44%), dwelling with habitation therapy (26%), subacute rehabilitation/SNF (19%), acute rehabilitation (v.5%), expired (2.5%), home with outpatient therapy (2%), and extended care facility without therapy (i%).

Table ane.

Patient Baseline Demographics

Mismatches

There was a mismatch between physical therapist recommendation and patient discharge location in 124 of 743 cases, or 17% of the fourth dimension. The breakdown by service groups was: neurology/neurosurgery, 21%; medicine, 19%; surgery, 16%; and trauma/orthopedics, 7%. Mismatches are categorized by belch location in Table 2 and by reason for mismatch in Table 3. The majority of mismatches occurred in patients who were discharged home. The about frequent reason for mismatch was patients who did not receive home therapy when recommended. The 2d largest group of mismatches were patients who received home therapy services that were non recommended, a condition that reflects unnecessary utilize of resources. Patient refusal of placement or services was the third largest category, and lack of insurance or insurance denial of services caused very few mismatches.

Table two.

Mismatch Condition by Discharge Location

Tabular array iii.

Reason for Mismatch by Belch Location

Although virtually mismatches occurred in patients who were ultimately discharged abode, mismatches in the "other" category of reasons for mismatch did include patients who were subsequently discharged to a subacute rehabilitation facility or SNF. These cases were scenarios where no beds were available at the recommended level of care in the patient'due south preferred geographical area or where patients were denied admittance to an astute rehabilitation facility despite the recommendation.

Readmission

Every bit shown in Table iv, 139 patients (approximately 18% of our sample) were readmitted to our hospital inside 30 days of their discharge. Our overall readmission rate is consistent with that of other studies.^{twenty , 23} In our logistic regression analysis to predict the probability that a patient would exist readmitted, mismatch condition, discharge location, and length of access were pregnant predictor variables. Patient age was non a pregnant predictor variable.

Table 4.

Patient Readmission by Mismatch Status

Table 5 shows the results of follow-up hypothesis testing. Holding all other variables abiding, a patient was ii.9 times more likely to exist readmitted when the therapist discharge recommendation was non implemented and services were defective compared with patients with a match (mismatch with services lacking versus match, odds ratio [OR]=ii.89, 95% confidence interval [CI]=1.57–v.30). Patients whose therapist belch recommendations were non implemented and who received dissimilar services or extra services were non significantly more probable to be readmitted than patients with a friction match (mismatch with different services versus match, OR=one.42, 95% CI=0.79–two.56).

Table five.

Odds of Readmission

Follow-upwards testing too revealed that patients discharged to an extended care facility were 6.ix times more than likely to be readmitted (OR=six.89, 95% CI=two.23–21.32) as compared to patients discharged home without therapy. The results for patients discharged to an acute rehabilitation setting approached significance in the direction of lower risk of readmission (OR=0.41, 95% CI=0.16–1.02) equally compared to patients discharged dwelling without therapy. In Effigy 1 we show the unlike readmission rates past discharge location.

Rate of readmission by discharge location. Overall readmission rate was xviii%, and patients discharged to extended care facilities without concrete therapy were significantly more than likely to exist readmitted to the hospital within 30 days.

Physical Therapists

The 40 therapists included in the sample had a mean of 110 months of full experience as a practicing physical therapist (range=3−354 months). As 23 of the physical therapists had career experience beyond the acute care setting, the range of acute intendance experience was the aforementioned; however, the hateful was lower (mean of 57.5 months of acute intendance experience).

Give-and-take

Overall, patients were discharged in accordance with the physical therapist discharge recommendation 83% of the time. When the discharge recommendation was not implemented and recommended follow-up services were not received, patients were 2.9 times more than likely to be readmitted to our hospital within 30 days of discharge. Together, these results indicate that therapists are able to integrate multiple factors contributing to the discharge needs of the patient to make authentic and appropriate belch recommendations.

An overall match rate of 83% between the therapist discharge recommendation and the patient's actual discharge location and services indicates therapists are able to successfully comprise all of the various factors involved in the belch planning process. This finding indicates that there is value placed on the therapist recommendation past the concluding discharge plan decision maker. It is possible, however, that in some cases the discharge recommendation happened to friction match the patient's actual discharge location without actually influencing the conclusion making of the nurse or do direction coordinator making the concluding conclusion. It is difficult for united states to explicate the patients who did not receive dwelling house physical therapy when recommended or the patients who received dwelling therapy services that were not recommended—by far the largest causes of a mismatch. Either situation is a poor issue, every bit information technology leads to a patient lacking in necessary services or unnecessary utilise of limited resources. These cases ultimately reflect a lack of communication between the concrete therapist and the exercise management coordinator, fifty-fifty though the therapist recommendations were clearly documented in the electronic medical record.

In the case of patients not receiving abode physical therapy that was recommended, it is possible that the therapist documentation was not completed earlier the discharge plan was in identify and no exact exchange about the recommendation took identify, or that the practise management coordinator did not value the data. Alternatively, it is possible that the patient was non receiving formal belch planning and, despite the therapist identifying the patient's need for services, no ane followed up to ready home therapy services. Interestingly, Mamon et al^{half dozen} reported a similar finding that 43% of patients over the historic period of 60 years who were discharged dwelling reported that they had an unmet need for physical therapy or rehabilitation services. Although concrete therapist recommendations were not reported in their study, the findings indicate that there seem to be a number of patients being discharged with unmet needs. Perhaps practise management coordinators need to screen patients for formal belch planning needs at discharge or subsequently discharge, not just at access. Patients lacking necessary follow-upward services are a problem that needs to be addressed, as our findings testify that when physical therapist discharge recommendations were not implemented and recommended follow-up services were not received, patients were 2.9 times more probable to be readmitted to our hospital.

As the U.s.a. struggles to balance efficiency and quality of health intendance, the ability of physical therapists to provide accurate and appropriate belch recommendations becomes even more important. Discharge planning is increasingly becoming function of an integrated package of health care, and even small reductions in readmission rates could gratuitous up capacity for subsequent admissions in a health intendance system where there is a shortage of acute infirmary beds.¹ Decreases in readmission rates, advisable allocation of resources, and avoidance of unnecessary services can help contain escalating wellness care costs.

Some other aspect of containing health care costs relates to the employment of physical therapists in the astute care setting. Since the initiation of the Medicare prospective payment organisation and its use of diagnosis-related groups, payments to hospitals accept been determined based on the patient's diagnosis, regardless of whether the patient receives services such every bit physical therapy. Acute care physical therapists take the claiming of justifying their salary cost to the hospital as outweighed past the do good to the patient and the hospital. This claiming is difficult for a number of reasons. Therapists often are consulted to work with the patients who are more than medically and functionally compromised—patients who are more likely to accept negative outcomes than their less compromised peers. In add-on, therapists often are advocating for additional services for patients, such equally discharge to a rehabilitation facility, and the patient's length of stay ofttimes increases every bit he or she waits for admission to another facility. These findings demonstrate that therapists benefit both the patient and the hospital through their crucial office in the discharge planning procedure. When therapist belch recommendations were implemented and recommended follow-upwardly services were received, the patient and the infirmary had an increased likelihood of positive outcomes through a decreased risk of readmission.

In addition to whether or non the therapist recommendation was implemented, risk of readmission also was partially predicted by the patient'due south actual belch location. Patients discharged to an extended care facility without physical therapy were 6.9 times more likely to be readmitted, whereas patients discharged to acute rehabilitation approached a significantly lower gamble of 0.4 times equally likely to be readmitted. This finding probably reflects the nature of illness and reason for admission of these patients, and possibly reflects the quality of follow-up care they receive. Patients unremarkably are discharged to an extended intendance facility without a recommendation for continued physical therapy because they are very ill with a poor prognosis for functional gains, whereas patients are discharged to an astute rehabilitation setting because it is believed that they volition tolerate and benefit from at least 3 hours per twenty-four hours of interdisciplinary rehabilitation. Acute rehabilitation patients as well go on to receive 24-hour nursing care and the other benefits (and drawbacks) of a hospital setting, whereas patients discharged dwelling house do not. Patients discharged to subacute rehabilitation or an SNF as well receive 24-hour nursing care and daily rehabilitation, only, for a diversity of reasons, have not been admitted to astute rehabilitation or discharged dwelling house. Farther speculation on the relationship betwixt discharge location and risk for readmission is across the scope and blueprint of our report.

Of further involvement, although we admit this information is specific to our facility, the frequency of mismatch was not evenly distributed beyond the different primary attending services that discharged the patients. Some services had a higher rate of mismatch than others. The charge per unit was highest for neurology/neurosurgery and lowest for trauma/orthopedics. One contributing factor may be the nature of admissions; the orthopedic surgeons perform a high book of planned surgeries compared with the trauma/orthopedics and neurology/neurosurgery services, which accept a lesser book of patients and larger proportion of unplanned admissions. Planned admissions allow patients adequate fourth dimension to confirm insurance benefits and consider discharge needs ahead of time.

Different frequency of mismatch also is probable related to the civilization of each service and differential value placed on the physical therapist recommendation, too as the slightly different processes by which advice is exchanged (eg, the presence or absenteeism of formal interdisciplinary meetings). Within our 4 weeks of representative information, evaluations provided by each physical therapist were distributed beyond the dissimilar services, fugitive undue influence of this phenomenon on our terminal results but still reflecting the service-specific rates of mismatch.

Limitations and Further Questions

The major limitation of our study is that information technology is unique to our facility and may have express generalizability to other acute care settings. The large size of our hospital leads to many staff members in each subject area, each of whom practices in an individual manner within the customs of their discipline and within the larger hospital community. Resident physicians and physical therapists rotate between service areas of the hospital, interacting with unlike members of the health care squad and providing care to dissimilar types of patients within each area. As an academic medical middle and level 1 trauma middle, the facility tends to intendance for patients who are more severely ill and complex, which certainly influences discharge locations and readmission rates.

In addition to the facility-specific aspects of our study, other limitations were that we collected limited information on the patients who received physical therapist evaluations. We did not address readmission of patients to hospitals other than our own and we did not assess the reason for readmission. Nosotros did not collect information on reason for access, severity of illness, comorbidities, or functional level of the patients, which is data that would allow us to empathise more than about patterns of recommendation for discharge location or rates of readmission. In a cognizant effort to respect patient privacy, we did non collect information on patient sex, race, or ethnicity, every bit we felt a give-and-take of how these variables might chronicle to discharge location and readmission rates was beyond the scope of our report.

In regard to tracking readmission only to our ain hospital, our readmission charge per unit reflects merely readmission to our hospital and is likely lower than an overall readmission charge per unit, as there are almost certainly patients discharged from our facility who were readmitted to facilities closer to their home. Although our readmission charge per unit needs to be interpreted in context, the proportion of mismatches should be authentic. Patients who were part of a mismatch should have been equally likely to be readmitted to our infirmary compared with an outside hospital. By not assessing the reason for readmission, we may have included patients who were readmitted for purely medical, and not functional, reasons. Overall, readmission for any reason reflects a failure of the discharge plan, which may have been avoided with proper supportive postdischarge care. A decline in physical function is known to contribute to emergency department visits in older adults.²⁴

Future research, with a larger sample size, could investigate how clinical experience influences the accuracy of discharge recommendations of astute care physical therapists. Nosotros besides call back it would be interesting to follow up with patients and gather their perception of their recovery and functional status in relation to their discharge services and location. Nosotros are peculiarly interested in the patients who were functioning at a level where both subacute rehabilitiation/SNF and home with home concrete therapy were viable options. In addition, nosotros were not able to address how frequency of acute care concrete therapist treatments influences belch locations, which may be of detail relevance in these "borderline" situations.

Conclusions

Overall, our data strongly support the role of physical therapists in discharge planning in acute care. Physical therapists demonstrated the ability to brand accurate discharge recommendations for patients with complex clinical presentations who are acutely sick; these patients were discharged in accord with the therapist belch recommendation 83% of the time. More important, we showed that the therapist belch recommendations were appropriate, every bit patients were 2.9 times more than likely to be readmitted when the belch recommendations were not implemented and recommended follow-up services were lacking.

The Bottom Line

What exercise we already know almost this topic?

Acute care belch planning is a complex process that involves clinicians from varied disciplines and the assessment of many factors. Physical therapists often are involved in discharge planning and make recommendations for follow-up services, but the accuracy and ceremoniousness of their recommendations accept not been studied.

What new information does this study offer?

This study indicates that physical therapists are able to integrate multiple patient factors to brand authentic and appropriate discharge recommendations. When the concrete therapist'due south recommendation was not implemented and follow-upward services were lacking, patients were more likely to be readmitted to the hospital.

If y'all're a patient, what might these findings mean for you?

If you are in the hospital and take any concern that you will not be fully functional at discharge, you should seek a concrete therapist'due south recommendation for the most advisable discharge destination.

Footnotes

All authors provided concept/idea/inquiry design, writing, data drove, and consultation (including review of manuscript earlier submission). Dr Smith and Ms Fields provided information analysis. Dr Smith provided project management. Ms Fields provided participants. Dr Smith and Ms Fernandez provided clerical support.

The authors thank the physical therapy staff at the University of Michigan Hospital for their participation and back up, peculiarly Casandra Redmon and Lauren Lobert for information collection. They also thank Diane Jette, PT, DSc, for her comments on the initial thought.

A poster presentation of this research was given at the Combined Sections Meeting of the American Concrete Therapy Clan; February 17–20, 2010; San Diego, California.

This publication was made possible with back up from the Oregon Clinical and Translational Research Institute; grant UL1 RR024140 01 from the National Center for Inquiry Resources, a component of the National Institutes of Health (NIH); and the NIH Roadmap for Medical Research. Dr Smith is supported by a National Establish of Aging Institutional Preparation Grant to Jeri Janowsky (principal investigator). During her PhD studies, she was supported by grant H424C010067 from the US Office of Special Educational activity and Rehabilitative Services to Dale Ulrich (principal investigator).

^*Microsoft Corp, One Microsoft Way, Redmond, WA 98052-6399.

^†SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

References

1. Shepperd Due south, Parkes J, McClaran JJ, Phillips C. Discharge planning from infirmary to dwelling. Cochrane Database Syst Rev 2003;3:CD000313 [PubMed] [Google Scholar]

2. Jackson MF. Discharge planning: issues and challenges for gerontological nursing: a critique of the literature. J Adv Nurs 1994;19:492–502 [PubMed] [Google Scholar]

3. Haddock KS. Characteristics of constructive discharge planning programs for the frail elderly. J Gerontol Nurs 1991;17:10–fourteen [PubMed] [Google Scholar]

4. Hickey ML, Melt EF, Rossi LP, et al. Effect of instance managers with a full general medical patient population. J Eval Clin Pract 2000;half-dozen:23–29 [PubMed] [Google Scholar]

five. Naylor One thousand, Brooten D, Jones R, et al. Comprehensive belch planning for the hospitalized elderly: a randomized clinical trial. Ann Intern Med 1994;120:999–1006 [PubMed] [Google Scholar]

six. Mamon J, Steinwachs DM, Fahey M, et al. Affect of hospital discharge planning on coming together patient needs after returning abode. Health Serv Res 1992;27:155–175 [PMC free article] [PubMed] [Google Scholar]

7. Bowles KH, Naylor Physician, Foust JB. Patient characteristics at hospital discharge and a comparison of home care referral decisions. J Am Geriatr Soc 2002;50:336–342 [PubMed] [Google Scholar]

viii. Wee JY, Wong H, Palepu A. Validation of the Berg Balance Scale every bit a predictor of length of stay and discharge destination in stroke rehabilitation. Arch Phys Med Rehabil 2003;84:731–735 [PubMed] [Google Scholar]

9. Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending discharge placement from the acute intendance setting. Phys Ther 2003;83:224–236 [PubMed] [Google Scholar]

10. Potthoff S, Kane RL, Franco SJ. Improving hospital belch planning for elderly patients. Wellness Care Financ Rev 1997;xix:47–72 [PMC free article] [PubMed] [Google Scholar]

11. Haddock KS. Collaborative belch planning: nursing and social services. Clin Nurse Spec 1994;8:248–252 [PubMed] [Google Scholar]

12. Gill TM, Williams CS, Tinetti ME. The combined furnishings of baseline vulnerability and acute hospital events on the development of functional dependence among customs-living older persons. J Gerontol A Biol Sci Med Sci 1999;54:M377–M383 [PubMed] [Google Scholar]

13. Boyd C, Landefeld CS, Counsell Due south, et al. Recovery of activities of daily living in older adults after hospitalization for acute medical disease. J Am Geriatr Soc 2008;56:2171–2179 [PMC costless article] [PubMed] [Google Scholar]

14. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc 2003;51:451–458 [PubMed] [Google Scholar]

15. Coleman EA, Min SJ, Chomiak A, Kramer AM. Posthospital care transitions: patterns, complications, and risk identification. Health Serv Res 2004;39:1449–1465 [PMC gratis article] [PubMed] [Google Scholar]

xvi. Ensberg MD, Paletta MJ, Galecki AT, et al. Identifying elderly patients for early discharge after hospitalization for hip fracture. J Gerontol 1993;48:M187–M195 [PubMed] [Google Scholar]

17. Jette DU, Dark-brown R, Collette North, et al. Physical therapists' management of patients in the acute care setting: an observational study. Phys Ther 2009;89:1158–1181 [PubMed] [Google Scholar]

eighteen. Curtis KA, Martin T. Perceptions of astute care physical therapy practice: bug for concrete therapist preparation. Phys Ther 1993;73:581–594; discussion 594–598 [PubMed] [Google Scholar]

nineteen. Guide to Physical Therapist Practice. 2nd ed.Phys Ther 2001;81:9–746 [PubMed] [Google Scholar]

twenty. Einstadter D, Cebul RD, Franta PR. Effect of a nurse case manager on postdischarge follow-up. J Gen Intern Med 1996;11:684–688 [PubMed] [Google Scholar]

21. Pagano M, Gauvreau K. Principles of Biostatistics Florence, KY: Wadsworth Publishing Co; 1993 [Google Scholar]

22. Resnik L, Liu D, Hart DL, Mor V. Benchmarking concrete therapy clinic performance: Statistical methods to enhance internal validity when using observational data. Phys Ther 2008;88:1078–1087 [PMC free commodity] [PubMed] [Google Scholar]

23. Bowles KH, Ratcliffe SJ, Holmes JH, et al. Postal service-acute referral decisions made by multidisciplinary experts compared to hospital clinicians and the patients' 12-week outcomes. Med Care 2008;46:158–166 [PMC complimentary commodity] [PubMed] [Google Scholar]

24. Wilber ST, Blanda Yard, Gerson LW. Does functional reject prompt emergency section visits and access in older patients? Acad Emerg Med 2006;13:680–682 [PubMed] [Google Scholar]

---

Articles from Physical Therapy are provided here courtesy of Oxford University Printing

---

penningtonseneiver.blogspot.com

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2867215/

Share this post