Referrals And DC Planning

Question 1

Important to know

Answer 1

Baseline/previous functional level

Change is status - why is there a change in status from baseline?

Question 2

DC potential members of the team

Answer 2

MD
Nursing
Case manager
PT, OT, ST
RT
RD
Social work 
Others
Pt family/support system

Question 3

D/C destination factors

Answer 3

Current level functioning compared to PFL

Support system

Living situation

Insurance

Safety

Question 4

Where will pts be distracted to from acute?

Answer 4

Home - I or w/ fam

Home w/ out pt PT

Home with home PT

Inpt rehab

TCU

ECF/SNF

Hospice

Question 5

Centers of care

Answer 5

Facilities that specialize in specific conditions

Ie MS, Parkinson’s CVA

Question 6

Transitional care unite/ long term acute

Answer 6

Pt requires SN care

Focus: medical manage of chronic condition

Pt not ready for intensity of acute rehab

Length of stay

Question 7

TCU/long term therapy provided

Answer 7

Less than 3 hours/day for 5-6 days/ week

Question 8

Long term care / SNF

Answer 8

Pt unable to be cared for a home and needs assistance w/ daily tasks

Pts is medically stable

May be step toward acute rehab

Team approach idea w/ therapies involved

Pt care may be coordinated by a nurse and MD

Question 9

SNF therapy is provided

Answer 9

30-60 mins/ day

Frequency may vary

Question 10

Assisted living facility

Answer 10

Between retirement home and SNF

Residents have certain criteria they must meet to reside here:

• medically table. May have chronic condition as long as managed and under control
• only requiring min A for ADLS
• primarily needing this type of living arrangement for safety
• once increased care or assistance is required, they may transfer to an extended care facility

Question 11

Acute rehab

Answer 11

Pt is in need of continued INTENSIVE rehab

Rehab nurses of staff

Rehab team hold weekly meetings to review case

Pt care is coordinate through a case manager

Question 12

Acute rehab - therapy

Answer 12

Pt must tolerate at least 3 hours of therapy/day for 5-7 days/ week

May include PT, OT, ST, recreational therapy

Question 13

Home health therapy

Answer 13

Pt is home, medically stable w/ proper resources for care

Must be “home bound” - inability to get transportation anywhere

Require skilled services

Strong social support

Paid my Medicare, commercial insurance, private pay

May be a step toward out pt therapy

Question 14

Outpatient clinic

Answer 14

Pt is living at home - has transportation to/from clinic

Nursing services are typically not included

Paid by Medicare, commercial insurance, out of pocked

Question 15

Outpatient clinic - therapy

Answer 15

Provided 2-3 times per week

Question 16

Going home/ family training - ID right person to train

Answer 16

Physical ability
Cognitive ability
Do they care?

Question 17

Readying the family to assist the pt in going home

Answer 17

Functional mobility

Equipment

Question 18

Family training - designated person should be

Answer 18

• safe and I w/ assisting pt with all of their needs related to PT
• capable of learning
• receptive to your input/instructions
• cognizant of their own body mechanics

**needs to be able to reverse demonstrate to the PT all that is required to be safe

Question 19

PT role in D/C planning

Answer 19

Good understanding of pt’s PFL

Pt’s level of function at time of d/c

DME recommendations

Communication

Question 20

Transitional living center

Answer 20

Some acute rehabs have a transitional place for patients getting ready to leave acute rehab

Stay of leave is longer

Insurance does have a play in this