5.1 Discharge Planning and Transitioning Care Flashcards
PEAR
P: Patient milestones
E: Education
A: Arrange Support
R: Report
P: Patient milestones
Vary based on the Pt condition and basline functional status
Inpatient setting
Mobility- what mobility milestones are required to:
* Enter their home (e.g. stairs to enter home - Pt must be able to ambulate 6 stairs independently)
- Navigate within their home (e.g. Pt lives in a small space and does not have room for a walker and must be able to ambulate with a cane)
- Transfer (e.g. Pt with a SCI needs to be independent transferring from bed to WC)
Medical status
- Are they** medically stable** or is there a plan in place to support their medical needs?
E.g.
* Pt require O2→reasonable to state: Pt no longer require O2 or a plan is in place for them to be discharged with home oxygen
- Pt post-op and have a wound→reasonable to state: Pt has follow-up plans for wound management
Outpatient setting
* Pt is at pre-injury level and successful with return to sport/activity or,
* Independent with rehabilitation and has progressed through treatment plan
**Reflect back on your patient-centered goals (e.g. return to running) and state that you would discharge once those milstones have been achieved
P: Patient milestones
What additional information is needed to provide a safe discharge home?
- Pt current physical and mobility status
* Level of independent: bed mobility, transfers, ambulation, stairs
* Balance and fall risk: any issues with falls while in the hospital? - Social history
Social Support
- If support needed, will there be someone to provide support (e.g. spouse, family member, friend, care aid)?
- What are will need the support? (ADL, cooking, mobility/transfer, transportation, execution of home exercises)
- Any transportation arrangements?
* Handi-Transit bus services, family member/friend, taxi/uber
Living arrangement (where will they be DC)
- Pt or friend/family member’s home, townhome or apartment:
→Are there stairs in/into the home
(how many steps and any railling, on which side?)
→ What level is the bedroom on?
- Rehabilitation facility/care home
→ Is there a waitlist to access the facility?
→ Are there specific mobility requirements that must be considered (e.g. minimum assist with transfers)?
Education
Educate the Pt and others involved in supporting the Pt
Educate the Pt and others involved in supporting the Pt
- Train family/friends and/or care aids
→How to assist with mobility, home exercise program etc
Education on safety
- Fall prevention:
→Avoding tripping hazards (remove carpets, items on floor)
→Use a nightlight
→Always wear appropriate footwear (avoid sandals, loose fitting footwear)
- Special instructions/exercises for home
- Warning signs/problem to look out for
Educate to return if impairment returns
Arrange support
Determine if any equipment is need
- Gait aids: WC, transfer board, walker, cane
- Bathroom: bath bench, raised toilet seat, railing/poles
- Bedroom: hospital bed
- Ramp to get in/out of house
Refer to another healthcare provider
- Look back at who you previously referred your patient to. If any of these providers need to be involved in discharge, state why you would involve them in the discharge process
- See Collaboration, Consultation, and Referral to Others for information on other healthcare workers who could be included in discharge planning
Refer for further PT services
* Government-funded services:
1. Outpatient physiotherapy service
→Rehabilitation in OPD of the hospital
→referral to that program should be made by the physiotherapist and the Pt should be provided with the information for OP services to ensure they know how to book follow-up rehab services after discharge from the hospital
- Community home care physiotherapy
→PT within their home through the provincial health authority
→referral to that program should be made by the physiotherapist and the Pt should be provided with the information about these services to ensure they know how follow-up rehab services will be carried out after discharge from the hospital
- Private practice physiotherapy services
Refer them to a list of possible providers of local private practice clinic
Provide options for appropriate community resource
* Community balance (e.g. falls prevention program)/fitness programs
* Community support groups (e.g. local stroke recovery group, PD support group
* Cardiac/pulmonary rehabilitation program
* Personal trainer for general fitness
* Health and wellness programs (smoking cessation, substance abuse program, weight loss program)
Report
- Outcome measures indicating status at the time of discharge (use the one from monitoring part)
- Goals that still need to be achieved
- Any barriers that may be limiting goal achievement:
- External factors: issues with living arrangements (no elevator), lack of home supports
- Internal factors: anxiety/depression, lack of motivation, non-compliance with exercise program
- A copy of their current HEP
- If you are sending your discharge/transition plan to another healthcare provider in the Pt’s circle of care, include your contact information
Case Examples: additional information
- No longer requires oxygen
- Able to ambulate independently with a cane, but requires a 4-wheeled walker for longer distances
- Pt still has a productive cough→sputum is clear
- Pt is anxious about having another acute exacerbation
How would you prepare this Pt for DC given their current status? (PEAR)
Patient milestone:
*Mobility status: *
- Given that the Pt is now able to ambulate independently with mobility aids,
Medically stable, extra support for medical needs?
- is medically stable
- and no longer requires oxygen,
→they can be discharged from PT
E: Education
Reinforce important Rx techniques
- Educate the Pt and others involved in supporting the Pt on PLB strategies to help with breathlessness and manage his anxiety about re-exacerbation
- Educate the Pt to continue with secretion clearance techniques until they no longer have a productive cough
Reinforce ADL management
- Educate the Pt on pacing and planning to manage return home
Reinforce self-management
- Ensure the Pt understands the role they need to play in their own recovery. We discussed these strategies during promoting self-management.
Arrange support
Equipment needed:
- Arrange for a cane and 4 wheel walker for home
Referral to further PT services:
- Refer to community physiotherapy to continue to help improve their strength and endurance while ambulating
Referral to community programs:
Provide options for…
- community fitness programs,
- emphysema support groups,
- pulmonary rehabilitation programs,and
- smoking cessation programs
if the Pt is open to participate in any these programs
Report
If you are not given any additional information, you should simply state what you would include in the summary
Outcome measure at DC:
I would include the following outcome measures in their discharge report:
- 6-minute walk test,
- auscultation findings,
- blood pressure,
- RPE at rest and during ambulation
Unrealised goal & any potential barrier
- I would include the goals that were not met or still need to be monitored
Pt HEP
- I would include a copy of their current exercise program
Send report to next PT/family doc
- With the Pt consent, I would send this report to the community physiotherapist they choose to see
- as well as their family doctor and
- include my contact information.
TKR Pt: ongoing Knee flexion limitation & LBP, but can’t afford more private community PT sessions
Patient Milestone
- Pt ambulation at pre-op level
- Return to function (ADL, driving)
- Knee flexion still at 100 (need to be ~120/allow Pt to complete activities with ease)
- Mild Lt knee pain & LBP (pain-free Lt knee/LB or effective strategies on how to ind. manage pain)
While this Pt has dec. knee ROM and ongoing pain issues, there are financial limitation so a change to the plan of care must occur
TKR Pt: ongoing Knee flexion limitation & LBP, but can’t afford more private community PT sessions
Education
- Ongoing limitation in knee ROM and pain and the importance of ongoing rehabilitation exercises
- Provide and educate on an effective HEP to address knee ROM restriction and pain issue
- Educate on options for ongoing service: more manageable finanically
- Transition to PTA service
- Transition to in-clinic session (if cheaper than home visit)
- Dec. session to bi-weekly/monthly/consult as needed
TKR Pt: ongoing Knee flexion limitation & LBP, but can’t afford more private community PT sessions
Arrange supports
- Provide options for additonal piece of equipment that can improve overall function/pain
E.g. TENS unit, hot pack, ice pack - Refer to SW to investigate options fro government-funded PT
- Community resources
- Community rec center fitness program (aquatic program)
- Pulmonary rehab (Pt is smoker)
- Smoking cessation program (Pt is smoker)
TKR Pt: ongoing Knee flexion limitation & LBP, but can’t afford more private community PT sessions
Report
Can be a progress report/DC report depends on the plan of care
I may not necessarily be discharging the Pt from care altogther.
I may be adjusting the program due to finanical restrictions such as using a PTA
Important to document all Pt interactions/discussion to ensure the chart contains the updated plan and rationale for change
