Factors influencing physical therapy discharge planning in the acute care setting.Background
The acute care physical therapist practices in a fast-paced environment and therefore, must be prepared to make clinical decisions by integrating a large volume of information in a short time. Acute care is costly and therefore, the goal in this setting is to move patients to the next appropriate level of care in a timely fashion. An extensive search of the literature yielded very little written regarding the physical therapist role in patient discharge process in the hospital setting. The Guide to Physical Therapist Practice acknowledges that the physical therapist has a role in discharge planning and describes this process.(1) Malone and Lindsay describe some of the elements of discharge planning that should be considered when an inpatient is discharged. (2) As academic coordinators of clinical education and faculty who teach acute care curriculum, we have come to the conclusion that one of the most difficult skills for the physical therapy student to master is discharge planning because so many elements are involved.
A survey was designed and sent to physical therapists currently practicing in an adult acute care setting. The questionnaire was designed to ascertain how the process was initiated, who initiated the process, and what role the physical therapist assumed in this process. We were particularly interested in what factors the physical therapists deemed important when making a recommendation for a discharge destination. The data on the surveys that were returned were analyzed and are presented here.
A survey was designed to collect demographic information and ask pertinent questions regarding the discharge process and the physical therapist's role in discharge planning in the 28 acute care hospitals in Connecticut. The survey included 5 demographic questions regarding the respondents and 7 questions regarding discharge planning. For ease of use, the survey included short answer and check list types of questions, and items were suggested that could be ordered by the respondents in terms of their importance in the discharge process. See Appendix 1.
Directors, managers, and supervisors of the physical therapy departments of the 28 acute care hospitals in Connecticut were initially contacted by phone to ask permission to send the questionnaires to their staff members. All of the rehabilitation management contacted agreed to allow us to send our surveys. We sent a specific number of surveys based on how many licensed full time, part time, and per diem/ casual status physical therapists the hospital had on staff at the time. We only included physical therapists actively practicing in acute care. For example, if the hospital had an outpatient department, we did not include physical therapists from that department unless they were also providing acute care services in the hospital. In all, 287 surveys were mailed, and 100 surveys were returned to us. Of the 28 hospitals that were initially contacted, surveys were received from 24 of them.
Physical therapists from twenty-four of twenty-eight hospitals in the state of Connecticut returned surveys. The average number of beds per hospital was 292.5. Characteristic demographic information is shown in Table 1.
Respondents indicated substantial numbers of years in practice, suggesting that our respondents were experienced clinicians. The range in years of practice of physical therapy was 1-45 years, with the mean number of years practice being 15.68 years.
We also asked how many years the respondents had practiced in acute care. Again, the range was 1-45 years with a median of 11.79 years in the acute care setting. Out of the 100 respondents, 76% were employed full time, 20% practiced part time and 4% were per diem/casual status employees.
To determine their familiarity in various settings with regard to potential patient discharge needs, participants were asked in what other types of facilities they had been employed. The majority of responses included practice in the outpatient setting (48%), although only 3% of respondents were employed in a private practice setting. Home care was the second highest response (33%) and previous experience in a skilled nursing facility was third with 28%. Other practice areas included subacute care (10%), long term care (7%), rehabilitation (acute rehab 20% & shortterm rehab 9%); and pediatrics (6%).
When asked to select all those who initiate patient discharge in their practice facilities, physical therapists most frequently identified discharge planners (89%) followed by physicians (79%). Only 27% of those surveyed identified PT/OT or rehabilitation services staff as an initiator of discharge. In addition, 64% of physical therapists surveyed stated that discharge notification was only "sometimes" done in a timely manner. A number of comments indicated that physical therapy departments received consults on the day of discharge thus negating any benefit the patient may have had from receiving physical therapy while hospitalized. Lack of timeliness of notification for a physical therapy evaluation may have also resulted in decisions regarding discharge destinations being made extremely quickly. In some instances, physical therapy evaluations may have been ordered as a final step to verify discharge destination, that is, to assess for appropriateness of plan for discharge or to assure insurance coverage.
With regard to discharge destinations, the surveyed physical therapists recommend discharge to the following destinations: home with homecare PT (99%), subacute rehab (98%), acute rehab (97%), and home with outpatient PT (96%). In addition, 87% referred to long-term care and 82% to home with specialized outpatient programs such as cardiac or pulmonary rehabilitation. These data support that physical therapists use professional judgment to discharge patients to destinations most suitable for patients and families and they do not hesitate to discharge patients to a wide variety of settings. Other settings identified were varied. Examples included home with 24 hour/7day per week care, assisted living and hospice.
Results of the survey also indicated that most hospitals (89%) do not have hospital-to-home programs with insurance companies that direct discharge destination. These data suggest that insurance agreements do not appear to be driving decisions on discharge destination.
An interesting survey result is that 51% of hospitals have formal affiliations with home care agencies. However, when analyzing survey results, home care does not appear to be utilized significantly more often than other discharge destinations. This would lend credibility to the fact that physical therapists placing patients in destinations endeavor to best serve the needs of patients and their families.
In an attempt to elucidate what factors the physical therapists considered most important when planning a discharge for a patient, we listed many of the factors that we ourselves considered when we discharge patients in our own hospital practice settings. We did this in an attempt to make this survey user friendly and quick to complete. We also included categories for "other" so that we would not miss any important factors that might not be issues in our own practice sites.
A grading system was designed and used to assess the factors. We assigned each of our characteristics a score based on the rankings that it received. Of the physical therapists that we surveyed, 54% rated "the ability to transfer and ambulate" as the most important factor in discharge planning. The "ability to transfer and ambulate" was rated the second most important factor by 23% of our population and third by 11% of our population, making it by far, the most popular choice. The "ability to transfer and ambulate" earned a total score of 197 points. 54 physical therapists ranked it #1, 23 physical therapists ranked it #2, 11 ranked it #3, 1 ranked it #4 in importance, 2 ranked it #5 in importance, 2 ranked it #6, 3 ranked it #7, 1 ranked it #8, 1 ranked it #9 and 2 respondents left it blank. The score was therefore computed as follows:
54 x 1 = 54
23 x 2 = 46
11 x 3 = 33
1 x 4 = 4
2 x 5 = 10
2 x 6 = 12
3 x 7 = 21
1 x 8 = 8
1 x 9 = 9
Total 197 points
We reasoned that the characteristics receiving the lowest scores were higher on the ranking, and therefore more important in the estimation of our respondents. Using this method, the other 2 characteristics that were close to "the ability to transfer and ambulate" were "the patient's cognitive status," which was given a score of 383, and "having a person at home to assist," which was given a score of 386. The patient's "home environment" received a score of 403, followed by the patient's "prior functional status," 514; patient "medical/ surgical diagnosis," 651; and patient's "community resources," 657. A list of the characteristics, rankings, and overall scores is delineated in table 2.
Discharge planning in an acute care setting is often a daunting task to a physical therapy student, a new graduate physical therapist and even an experienced physical therapist who is entering the acute care arena for the first time. Clearly, many factors need to be considered in a short period, especially when discharge planning is often initiated the day before or even the day of discharge as was indicated by many of our respondents.
The most important factors in discharge planning identified by our respondents were "the ability to transfer and ambulate," "having a person at home to assist," and "the patient's cognitive status." These were aptly termed, "the big three" by one of our respondents, but clearly, other factors need serious consideration such as the patient's home accessibility, community resources such as availability of visiting nurses and meals on wheels, and even the patient's insurance and financial resources.
To prepare the physical therapy student or physical therapist unfamiliar with the acute care setting, training to assess these characteristics is necessary. Our demographic profile of respondents revealed, for instance, that 33% had some experience in home care. This group of individuals would be very aware of the factors that would influence recommendations to discharge a patient to home and what services would be required. Many limitations imposed by Medicare and other third party payers impact discharge decision-making. This might not be as evident to a physical therapy student who may not be proficient in collecting information on an environmental assessment or insurance coverage.
Knowledge of the many discharge destinations, what they provide, and what they require of the patient is also necessary. A patient going to an acute rehabilitation facility needs to be able to participate in three hours of therapy per day. The acute care physical therapist must be aware of this fact, and then be able to decide, based on possibly only one evaluation session, whether the patient will be able to meet this requirement. A patient who will be receiving services at home most often has to meet the requirement of being "homebound" or insurance will not pay for the services. A local rehabilitation center may not take a certain patient because of the care he or she requires. Examples include ventilatory support, intravenous therapy, or wound care. The physical therapist needs to be cognizant, therefore, not only of the patient's needs upon discharge, but what the local facilities can provide.
Discharge planning in the acute care hospital is a highly skilled process that requires a physical therapist to evaluate a patient and make judgments about discharge in very short periods. This survey offers insight into the practice of discharge planning and the types of information that must be obtained and processed quickly to develop an optimum discharge plan for the patient.
This survey was an initial attempt to describe factors involved in the discharge planning process. The limited sample of convenience included only acute care hospitals in the state of Connecticut. Additional research is needed. The survey should be expanded to include other regions of the country where resources may be different and other factors may need to be considered. Students completing an acute care internship should be surveyed to determine their perceptions of their preparedness to take on the task of discharge planning. Results of a student survey in combination with clinician surveys such as this one would be a valuable resource in future curricular development in acute care and discharge planning and also provide a basis for increasing the effectiveness of discharge planning in the acute care setting.
Appendix 1. 7. Do you think that physical therapy is consulted in a timely fashion in the discharge process in your hospital? Yes -- No -- Sometimes -- Comments? -- 8. Discharge destinations which I have recommended for my patients include: (please check all that apply). Acute rehab -- Sub acute rehab -- Long term care -- Home with home physical therapy -- Home and to out patient physical therapy -- Home and to specialized program, for example, out patient cardiac rehab -- Other (please indicate where) -- Other (please indicate where) -- 9. Below are listed some factors that have been reported to influence discharge recommendations: (please rank in order with #1 being the most important and subsequent numbers (#2, #3, #4, etc) being less important as to how you would decide on a patient's discharge destination.) Please add and rank any that you think are missing on this list. Prior functional status -- Medical/ surgical diagnosis -- Person at home to assist -- Patient's ability to transfer and ambulate -- Patient's cognitive status -- Home environment (for instance stairs or handicap accessible)-- Community resources available (VNA, meals on wheels) -- Patient's level of pain and how well pain is controlled -- Patient's financial resources -- Patient's insurance -- MD recommendation -- Family preference of discharge destination -- Patient's preference of discharge destination -- Other -- Other -- Other -- 10. Does your hospital have any hospital to home programs that you are aware of in conjunction with any insurance company that direct discharge destination? Yes -- No -- 11. Does your hospital have a formal affiliation with a home care agency? Yes -- No -- 12. Factors that influence my decisions on frequency of care for my patients include which of the following? Please check all that apply. Please add any that are missing. Medical/ surgical diagnosis -- Clinical pathway -- Discharge destination -- Availability of staff to meet frequency -- Physician order -- JACHO requirement -- Policy of physical therapy department -- Physical therapist clinical judgment -- Insurance requirements -- Lack of insurance -- Other -- Other -- Other --
(1.) Guide to Physical Therapist Practice. 2nd Ed.
(2.) Malone DJ, and Bishop Lindsay, KL.,eds. Physical Therapy in Acute Care: A Clinician's Guide. Slack Incorporated.2006.pp 20-24.
Christine Kasinskas, PT, DPT, Marie Koch, PT, MS & Rosemary Wood, PT, DPT
Christine Kasinskas, PT, DPT is Assistant professor of Physical Therapy at Quinnipiac University. She has practiced physical therapy for thirty-four years in various settings including acute care, home care, outpatient, rehabilitation, and pediatrics. She has performed research in balance, gait, and falls in the elderly at the University of Connecticut Health Center and Yale University School of Medicine. She teaches acute care and cardiopulmonary physical therapy curriculum at Quinnipiac University and also is an Academic Coordinator of Clinical Education. She currently practices on a per diem basis for Eastern Rehabilitation Network in home care at the VNA Healthcare and at St. Mary's Hospital in acute care. Both agencies are in Waterbury. CT. She is a member of the Acute Care, Cardiovascular and Pulmonary, and Home Care sections of the American Physical Therapy Association.
Marie Koch, PT, MS is Assistant Professor and Director of Clinical Education in the Department of Physical Therapy at Quinnipiac University. Since she began her career as a Physical Therapist forty-four years ago, she has been involved in direct patient care with the older population. She has practiced in a variety of settings including acute care, skilled nursing facilities, home care and outpatient clinics. She was the Director of the Geriatric Education Center for West Texas. She also performed research with Dr. Mary Tinetti of Yale University Medical School concerning balance and falls prevention in the older population. Presently, she continues her work with the older population by leading an exercise class for patients with Parkinson's disease. She also serves on the Board of Directors of the Connecticut Chapter of the American Parkinson's Disease Association. She is a member of the Geriatric and Education sections of the American Physical Therapy Association. She holds basic and advanced clinical instructor (CI) credentials and is certified trainer for both levels of CI credentialing. Her current research interests are in clinical education and geriatrics.
Rosemary Wood, PT, DPT is Assistant Professor in Physical Therapy and Academic Coordinator of Clinical Education at Quinnipiac University, where she has taught in both the acute care and administration portions of the curriculum. She has practiced in acute care for over 25 years, as well as in short term rehab and skilled nursing care. She developed one of the first JACHO accredited short-term rehabilitation programs in Connecticut while she was Director of Rehabilitation at the Hebrew Home & Hospital. She participated in research for the Fox vs. Bowen case which was a landmark Medicare decision involving hip fracture rehabilitation. Rosemary is a member of the Acute Care, Education, and Geriatric sections of the APTA. Currently, she practices at John Dempsey Hospital as a per diem acute care therapist.
The authors gratefully acknowledge the assistance provided by John Kasinskas BA, MS, MBA, in statistical analysis for this project.
Table 1. Trauma Center L I or L II Teaching Hospital City Hospital Community Hospital 27.5% 42.5% 27.5% 42% Table 2. Rating PFS MSD PAH PATA PCS HE CR 1 15 4 6 54 14 4 1 2 10 6 26 23 16 16 3 3 6 3 19 11 18 22 1 4 12 5 20 1 18 21 2 5 16 11 9 2 11 12 9 6 9 14 8 2 10 12 15 7 6 10 4 3 4 1 20 8 5 9 0 1 3 6 13 9 5 5 3 1 0 1 10 10 4 12 2 0 0 1 5 11 3 9 1 0 4 1 4 12 0 4 1 0 0 0 2 13 5 1 0 0 0 0 4 TOTAL 514 651 386 197 383 403 657 Rating PAIN PFR INS MD FMPREF PTPREF 1 1 1 7 0 2 6 2 0 2 3 2 6 6 3 6 1 3 2 2 5 4 5 3 2 1 2 7 5 5 1 1 1 10 5 6 6 1 0 3 5 7 7 19 3 6 3 6 9 8 15 8 6 4 10 13 9 13 10 9 12 13 6 10 6 13 11 17 9 10 11 4 10 15 15 9 10 12 7 21 19 10 11 7 13 3 16 9 17 8 2 TOTAL 697 920 826 903 772 669 PFS-prior functional status; MSD-medical/surgical diagnosis; PAH-person at home to assist; PATA-patient's ability to transfer and ambulate; PCS-patient cognitive status; HE-home environment; CR-community resources; P Pain-Patient's pain and how well it is controlled; PFR-prior functional status; INS-insurance; MD-physician recommendation; FMPREF-family preference; PTPREF-patient preference.