Discussion w15 650

Q-1

I would recommend a short term acute rehab for the patient due to the patient's difficulty walking. This difficulty in mobility is one admission criteria, but we can expand this to include problems in the activity of daily living, and transfers (Bielecki & Tadi, 2020). The other side is that there are special pieces of equipment that can help the patient advance quickly that are unable to be obtained at the home such as a Hoyer lift (Bielecki & Tadi, 2020). However, there are requirements that the patient has to be able to perform or agree to. Such requirements include being able to participate in at least three therapies a day, three hours of therapy for five days a week, and is agreeable to participate (Bielecki & Tadi, 2020). 

If the patient can meet the criteria, most insurances will issue precertification or speak with the case manager to apply the patient's benefits to a rehab facility, and most of the time the insurance will elect to pay for a rehab stay (Smith, Kulhari, Wolfram, & Furlan, 2017).  

I have found acute rehabilitation facilities to be highly beneficial for many reasons. These facilities are able to provide intense training programs that are patient-specific and designed to bring the patient back to their prior level of functioning as quickly as they can. I would not want to see a patient who has been deconditioned to the point of motility issues return to the hospital because of a fall, or a subsequent injury from a fall. 

Also, there is the timing aspect. For example, home health has a limited amount of availability per week, so this patient may only receive three one-hour sessions per week, increasing the time it takes for the patient to return to their prior level of functioning. This increase in return time also increases the risk of an injury due to decreased mobility. While rehab facilities can perform multiple rehab sessions per day for these patients to quickly return their lost strength.

I would evaluate each patient individually, but in my opinion, I would still elect to send this patient to an acute rehab facility in order to gain his strength back as quickly as possible. There are some things we can weigh against the decision such as evaluation of the patient's home status. For example, if the patient had the ability to even have the specialized equipment in the home, or family members who were physical therapists. I think this would be the only exception to where I would change my mind and write for home health.

References:

Bielecki, J.E., Tadi, P. (2020) Therapeutic Exercise. StatPearls Treasure Island StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK555914/

Smith, A. L., Kulhari, A., Wolfram, J. A., & Furlan, A. (2017). Impact of Insurance Precertification on Discharge of Stroke Patients to Acute Rehabilitation or Skilled Nursing Facility. Journal of Stroke and Cerebrovascular Diseases, 26(4), 711–716. https://doi-org.lopes.idm.oclc.org/10.1016/j.jstrokecerebrovasdis.2015.12.037

Q-2

A safe discharge would depend on the patient, the home situation, and the patient needs. If a patient is recovering slowly it could be beneficial for them to go to a rehab facility for help and supervision. The patient isn’t ambulating well and if he lives alone that wouldn’t be a safe discharge as this could increase risk of falls, decreased mobility, and deconditioning. PT/OT would be beneficial to the patient to improve mobility and safety. Requirements include the need of therapy for 3 hours of therapy for 5-7 consecutive days for physical therapy, occupational therapy, and speech/language therapy, they need nursing assistance with specialized training, a case manager, and the expectation that the patient will benefit from therapy (Forrest, et al., 2019). I would begin with getting a PT/OT consult in the hospital and assess for general patient safety. I would use their recommendations to guide my decision and recommend the appropriate services. I would then ask about home life and what type of house he has, what help he has at home, and if he had a plan with getting help if he lived alone (such as having a friend/family stay with him). I would then assess patient’s cognitive function and the ability to safely decide on what he wants. If he was deemed safe to go home with home health services, then I would be ok with sending him home with that. He would get the help he needs, and someone would be able to check on him. There is a benefit of less chance of complications with being at home versus in a facility. The rehabilitation at home and in a facility of knee replacements was evaluated and shown there was no significant difference besides the reduced post-discharge complications (Buhagiar, et al.,2017). If the patient isn’t safe to go home and requires intensive rehabilitation and continuous supervision then the rehabilitation facility would be the safest discharge for the patient.

 

Buhagiar MA, Naylor JM, Harris IA, et al. Effect of Inpatient Rehabilitation vs a Monitored Home-Based Program on Mobility in Patients With Total Knee Arthroplasty: The HIHO Randomized Clinical Trial. JAMA. 2017;317(10):1037–1046. doi:10.1001/jama.2017.1224

Forrest, G., Reppel, A., Kodsi, M., & Smith, J. (2019). Inpatient rehabilitation facilities: The 3-hour rule. Medicine, 98(37), e17096. https://doi.org/10.1097/MD.0000000000017096

Q-3

A 72-year-old male with a past medical history for hypertension, congestive heart failure, chronic back pain, and diabetes is admitted to the hospital for hypotension suspected from a possible accidental overdose. What are the criteria for discharge? Explain the importance of utilizing hospital recommendations and teachings. List some meaningful community resources in the response.

Discharge planning is characterized as a development of an individualized discharge plan of the patient before leaving the hospital to ensure that the patients are discharged at the right time and that adequate resources are given after discharge (Alper et. al, 2020). Patient cognitive status, activity level, and functional status, nature of the patient’s current home and suitability for patient’s conditions, family support, transportation from the hospital to home and follow- up visits, and the availability of services in the community to assist the patient with ongoing care are some of the factors that providers consider when deciding where to send the patient after hospitalization. One of the hospital standards when discharging patients in the hospital is a discharge summary. A discharge summary is an important tool that is written by the discharging physician that is usually reliable and standardized to ensure that there will be clear communication about the hospital course(Sponsler,2017, p. 94). The recommended components of the discharge summary are the primary and secondary diagnoses, pertinent test results, pending results, patient’s condition at discharge, recommended additional workup or treatment plan, a complete list of the reconciled medications, follow-up arrangements, resuscitation status, documentation of patient education and identification and contact information for the sending and receiving providers (Sponsler,2017, p. 94). In this case, providers need to ensure that the medication is reconciled properly and the instructions are clear to prevent any errors or adverse effects such as hypotension to the patient. Patients need to be educated and instructed on how to prevent falls while at home and to make sure that the patient is capable of safely preparing and taking their medications on time. Also, providers need to identify any pending results and follow-up appointments after discharge. It is also important that patients who have the chronic condition is well-informed about their disease, the disease process and what can they do to prevent further exacerbation or hospitalization. Some of the community resources such as adult day health, pharmacies that offer blister packs, medication therapy management, and those pharmacies that deliver medications at home are available in elderly or disable patients.

References:

Alper, E., O’Malley, T.A. & Greenwald, J (2020).  Hospital discharge and readmission. Retrieved from https://www.uptodate.com/contents/hospital-discharge-and-readmission#H8

Sponsler, K.C. (2017). Care transitions at hospital discharge. S.C. McKean, J.J., Ross, D.D. Dressler, D.B. Scheurer (Eds). The

Principles and Practice of Hospital Medicine 2nd edition (pp. 90-96). Mcgrawhill education.