By: Allison Rowe, SPT
(1)
Overview
My third clinical rotation over the summer of 2013 was my acute care rotation on a trauma floor. I thoroughly enjoyed my time on this rotation, and left my experience amazed at how much I had learned, and how much more I felt there was to learn. In particular, one area that I continually struggled with was the process of discharge planning for patients. When beginning to think about our capstone project, I felt passionate about somehow sharing what I had learned over my rotation and what I hoped to learn in our Evidence Based II (PHYT 752) class with other PT students.
During our EBP II class I posed the PICO question: Among acutely ill patients being discharged from a hospital, are hospital readmission rates higher when discharge location follows physical therapist recommendations or when discharge location is inconsistent with physical therapist recommendations? This question is important not only for our profession, but for our evolving healthcare system. With implementation of the Affordable Care Act in 2010, changes in our healthcare system are shifting to focus on reducing unnecessary healthcare costs, such as preventable hospital readmissions.1-2
Smith et al3 directly addressed my PICO question in a retrospective study, where it was found that a patient was 2.9 times more likely to be readmitted to the hospital when therapist discharge recommendations were not implemented.3 These conclusions were drawn using data from one large hospital. With expansion of the sample population these results would be of higher quality. However, these results strongly establish a need for physical therapist involvement in the discharge planning process and are made stronger when considered with the other articles in the literature review. My literature review for my PICO question along with my evidence table for this capstone project are available below to provide a basis of available information pertaining to the topic.
Rowe_Capstone Evidence Table 2014
As demonstrated by the findings of my literature review to answer the above PICO question, an understanding of and knowledge about the multitude of factors involved in effective discharge planning are essential for a physical therapist practicing in acute care. Discharge planning is a skill that is difficult for physical therapy students to master due to the many components involved.4 Considering the important role that a physical therapist has been shown to play in the discharge planning process and the effects that physical therapist recommendations have on patient outcomes3, it is imperative that physical therapy students obtain and possess the necessary knowledge involved in effective discharge planning. Together with an identified consensus between current students about a general lack of acute care discharge planning education in the UNC-CH DPT curriculum, my review demonstrated a need for an educational module on discharge planning for physical therapy students.
Final Products
My capstone project consisted of multiple parts. The first is an updated version of an existing educational module for students titled “Physical Therapy in the Acute Care Setting”.
Rowe_Capstone Acute Care Powerpoint
The intended audience for this presentation is first year physical therapy students of the UNC-DPT program. The educational module is a part of the PHYT 720 “Introduction to Physical Therapy Assessment and Procedures” class. Students are to read through the presentation and take a quiz on Sakai to demonstrate their understanding of the material as a requirement for class.
The second part of my capstone is a presentation I created titled “Discharge Planning in Acute Care Physical Therapy”. This was created as a voice thread presentation, available here:
Discharge Planning in Acute Care Physical Therapy Voice Thread
Here is the Discharge Planning capstone PDF version of the PowerPoint presentation to allow individuals to follow along on paper if they want to.
This presentation is intended for third year physical therapy students as a self-study module. The purpose of the presentation is to provide the learner with information pertaining to a physical therapist’s role in the discharge planning process, especially in the evolving healthcare climate. The presentation provides the learner with information about a complexity of factors that are involved in discharge planning decision-making. The information presented serves as either a refresher of information or as instruction, depending on a student’s experience. A self-study evaluation quiz was also created to help students evaluate their retention of the information presented.
Rowe_Discharge planning self quiz
Special Thanks
I would like to extend a special thank you to my advisor Dr. Lisa Johnston who helped me turn my ideas into practical, applicable capstone products. Lisa: Thank you for keeping me on track and supporting me through every step of the way. Knowing you were there if I needed help at any point was a comfort I was grateful to have! I also want to thank my two committee members, Lauren Susco, PT, and Michelle Anderson, PT. Lauren: Thank you for all of your suggestions, feedback and positive support – I couldn’t have done it without you! Miki: Thank you for your valuable feedback and for letting me update your acute care PowerPoint! I am grateful to have both of you on my committee!
Thank you for visiting my capstone website! I look forward to hearing feedback. If you have any questions or would like to provide feedback to me directly, please feel free to contact me at allison_rowe@med.unc.edu.
References
- Image available at: https://www.openplacement.com/uploads/op/files/elderly-woman-to-a-nursing-home.jpg. Accessed April 16, 2014.
- Delisle D. Care Transitions Programs: A Review of Hospital-Based Programs Targeted to Reduce Readmissions. Prof Case Manag. 2013; 18(6): 273-283.
- Costantino M, Frey B, Hall B, Painter P. The Influence of a Postdischarge Intervention on Reducing Hospital Readmissions in a Medicare Population. Popul Health Manag. 2013;16(5): 301-316.
- Smith B, Fields C, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Phys Ther. 2010; 90: 693-703.
- Kasinskas C, Koch M, Wood R. Factors Influencing Physical Therapy Discharge Planning in the Acute Care Setting. Acute Care Perspectives. 2009.
5 Responses to “Discharge Planning in Acute Care Physical Therapy”
Lisa Johnston
Allison:
Excellent job on your capstone. I am looking forward to integrating this into next year’s class. I appreciate all your hard work!
Lisa
Allison Rowe
Jessica,
Thank you so much for your feedback also! It’s so nice to hear you say that you felt like everything was laid out in a step-by-step format, because that’s exactly what I was going for. I focused on making sure it was easy to follow along with, but had enough information that it would be a good resource to use on a clinical rotation. The same goes for the outcome measures that I discussed. Like you said, not many acute environments use outcome measures but I definitely see that changing as our healthcare system shifts. I hope that this can serve as a resource to allow students to make suggestions when they are off on clinicals!
Allison
Allison Rowe
CJ –
Thanks for your feedback! The majority of the mismatches in the Smith et al study occurred in patients who were discharged home when they did not receive recommended home therapy.1 The authors did not go in to detail about why these services were not received. I did want to comment, though, that this was actually a theme that developed throughout my review; a correlation between patients being discharged to their home and the higher risk that this puts them at for readmission.1,2 This is an important clinical finding when attempting to identify methods to decrease hospital readmission, and should be explored further. The potential for identifying barriers to patients receiving recommended home physical therapy following hospital discharge could give us insight in to changes that should be made to improve patient care and follow up, thereby reducing readmissions.
Thanks again for your feedback, I hope you found it helpful!!
Allison
1. Smith B, Fields C, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Phys Ther. 2010;90:693-703.
2. Lockery S, Dunkle R, Kart C, Coulton C. Factors contributing to the early rehospitalization of elderly people. Health & Social Work [serial online]. August 1994;19(3):182-191.
Jessica Burpee
Fantastic job! Reading through your project I felt as if I re-learned everything from my acute rotation (and may have possibly forgotten since being out of that practice setting!). The step by step instructions for the chart review, evaluation, and D/C planning is an excellent format for understanding how the acute care process works. I feel that this can be a foreign area of practice for many first year students and the examples, hints, and information you provided in a great introduction to this practice setting. Also, thank you for providing information on relevant outcome measures to use in the acute setting. From my personal experience, outcome measures are rarely used in this setting and knowing the appropriate measure to choose would be difficult for me. However, as reimbursement policies change, knowing the outcome measures to best use the acute setting is an very valuable resource.
Catherine Jacobs
Allison,
I think your capstone project is very important for so many reasons, and you have done a great job with everything! First, like you say, this information is very important as our role continues to develop in the changing health care system. The information and stats you gathered during our EBP II course make a compelling argument for PT that would be valuable for many hospital systems to know! When I was in acute care, I sometimes heard PTs verbalize concerns that other professionals didn’t read their recommendations. Our hospital system was still using paper documentation at that time, and I imagine that computer documentation may help facilitate easier “discussion” between providers. I was surprised to read in your EBP paper that a patient was 2.9 times more likely to be readmitted when the therapists discharge recommendations were not implemented! Did you read any information that discussed about why therapy recommendations wouldn’t be followed? Was it discrepancies between therapists recommendations and what the patient wanted, or was it a disagreement between providers?
Your final capstone products will also be awesome resources for current physical therapy students. I have to admit that I didn’t even know what a SNF was when I got to my first rotation in acute care. Not only that, but discharge planning was intimidating as you are being asked about recommendations on the first day, when your basic evaluation skills are still just developing! I think the Powerpoint is a great resource for first years. The information on the slides is detailed enough to help you have a grasp on this part of our role in acute care, but basic enough that it isn’t too overwhelming. The PDF that is more targeted for third years is also a great resource. I am glad you started this with information about the ACA, and that you included financial considerations (such as details about Medicare). Thanks for all of your hard work, I will definitely use your final products as resources in the future!