Discharge planning begins at admission. Let me repeat: Discharge planning begins at admission.
Unfortunately, more often than not, discharge planning begins the night before or the morning of discharge. This does not work. The proper discharge planning leads to a much more successful outcome. The proper guidance will ensure a smoother transition. When the discharge plan is done early and communicated correctly, it gives the patient, his family, and his care providers a complete understanding of all the details and needs required, which yields better implementation of the plan with improved results--both medically and emotionally.
Recently I had a case where the patient needed to go to acute rehabilitation. I had spoken to his physicians, the hospital rehab department, the family; everyone involved agreed he needed acute rehabilitation. I had him evaluated by an acute rehab facility; he was accepted into the program and there was a bed for him.
And yet at 4:30 in the afternoon, the day before his morning discharge, the family was told to go look at a sub-acute rehab facility.
Why does discharge so often get screwed up, especially in this case when all the work was already done? Are discharge managers that overwhelmed? Do hospitals require that they refer only to rehabilitation facilities owned by the hospitals? Do they just want the bed and toss the patient to the first available rehab they can find? Are there kickbacks? I don't know, pick one!
The quality and quantity of rehabilitation can affect a patient for the rest of their life. In this case, my client had a massive stroke and was deemed unlikely to walk again. Even so, he was a candidate for and would benefit greatly from acute therapy.
It took the patient advocate again calling all caregivers involved and requesting the physiatrist, cardiologist, and neurologist directly call the discharge manager, in order to get the discharge plan revised. My client did go to the excellent acute rehabilitation facility. I can't express enough what a difference that made to his life and his family. Thanks to the excellent therapist and caregivers at the acute facility he did actually walk. This would never have happened had he gone straight into sub-acute.
The takeaways here are all patients and their families need to know all of their options, and the discharge planning needs to start at admission. Hospitals need to make sure families know the differences and the outcomes expected between acute and sub-acute facilities, and they need to know why a discharge manager is referring them to a particular facility. As part of discharge planning, patients should be given information and options for several facilities, and more importantly, there needs to be full disclosure when the hospital is self-referring. Such information can help your patients make informed decisions, which should be a standard of care, even at discharge.