Improving Speech, Occupational, and Physical Therapy Outcomes in Skilled Nursing Through Effective Discharge Planning

-Written by Shraddha Majcher

When a loved one experiences a fall, injury, or illness requiring hospitalization and skilled nursing rehab, families often experience a mix of emotions—hope, uncertainty, guilt, and stress. They may struggle with medical jargon, insurance issues, financial planning, and decisions about post-acute rehab care.

Effective discharge planning is essential for ensuring a smooth transition from speech, occupational, and physical therapy services, whether returning home with additional support or moving to a new care setting. Compassionate planning helps patients maintain progress, enhance safety, and reduce hospital readmissions while empowering families to make informed decisions. This post explores key components of effective discharge planning.

1. Comprehensive Patient Assessment

Discharge planning begins with a thorough evaluation of the patient’s physical, cognitive, and emotional status. Therapists assess mobility, balance, fall risk, strength, endurance, and cognitive function to determine the level of assistance required at home. The goal is to rehabilitate the patient to their prior level of function, but some adjustments to their living situation may be necessary. Families may need to provide additional support or arrange for services such as in-home caregivers, meal delivery, or medication management. In some cases, transitioning to assisted living, a family member’s home, or long-term care may be necessary.

2. Family Involvement in Discharge Planning

Family involvement is crucial, particularly for patients requiring continued support. Early and ongoing communication helps set realistic expectations and prepares families for caregiving responsibilities.

Key Steps for Family Engagement:

• Input on Goals: While patient involvement in setting rehab goals is a priority, family observations provide valuable insight into the patient’s prior function, helping set realistic expectations.
• Family Meetings: Discussions with the rehab team about progress, limitations, and discharge recommendations ensure families understand the roles of each provider.
• Active Participation: Encouraging families to observe therapy sessions allows them to learn about mobility techniques, exercises, and safety strategies.
• Caregiver Training: Hands-on education on safe transfers, assistive devices, and home exercise programs ensures families are prepared to assist with daily care.

3. Home Safety Assessment

A patient’s home environment plays a vital role in their recovery and safety. A home safety assessment—conducted in person or through discussion with the family - identifies risks and necessary modifications.?????

Key Areas to Evaluate:

• Fall Hazards: Removing loose rugs, improving lighting, and decluttering walkways.
• Bathroom Safety: Installing grab bars, non-slip mats, shower chairs, and raised toilet seats.
• Accessibility: Adding ramps, stair railings, or modifications for mobility devices.
• Emergency Preparedness: Ensuring access to emergency contacts and assistance plans.

When in-home assessments are not possible, therapists provide checklists to help families make necessary adjustments.

4. Remote Monitoring for Post-Rehab Care

Several companies have introduced new technologies that help enhance post-rehab care through remote monitoring that tracks patient recovery progress and adherence to treatment plans. Wearable devices, apps, and telehealth platforms monitor mobility, heart rate, oxygen levels, pain, medication compliance and other functions influencing recovery.? A company called “OneStep” is a recent example.? Their wearable device and mobile-phone-based app, captures real-time data to help prevent falls.? By providing information on gait, range of motion, risk, and other key indicators, clinicians can preemptively identify fall risk and introduce the interventions necessary to help prevent them.? The data is seamlessly integrated into the provider’s EHR system to support regulatory compliance and medical necessity.????

Benefits of Remote Monitoring:

• Early detection of complications, reducing hospital readmissions.
• Improved continuity of care between inpatient and home settings.
• Increased patient engagement in their recovery.
• Real-time data for caregivers to provide better support.
• Objective data to demonstrate medical necessity
• Customizable care plans based on patient progress.

5. Education on Assistive Devices and Equipment

Many patients require assistive devices for mobility and independence. Therapists educate patients and families on their proper use. Proper training helps families assist with these devices safely and effectively.

Common Equipment Includes:

• Mobility Aids: Walkers, canes, crutches, and wheelchairs tailored to the patient’s needs.
• Orthotics and Braces: Devices to support joints or improve gait mechanics.
• Transfer Equipment: Gait belts, slide boards, and mechanical lifts for safe transfers.

6. Developing a Personalized Home Exercise Program (HEP)

Rehabilitation continues after discharge with a structured home exercise program to maintain progress and prevent regression.

Key Components of an Effective HEP:

• Individualized Exercises: Strength, balance, flexibility, and endurance exercises tailored to the patient.
• Clear Instructions: Simple guidelines with visual aids or written directions.
• Frequency and Duration: Specific recommendations on how often exercises should be performed.
• Safety Tips: Guidance on proper form and recognizing signs of overexertion.

Family support plays a crucial role in ensuring adherence to the exercise program.

7. Addressing Medical and Personal Care Needs

Patients with complex conditions may require coordinated medical and personal care services post-discharge.

Key Considerations:

• Home Health Services: Nursing, physical therapy, occupational therapy, and speech therapy.
• Personal Care Aides: Assistance with daily activities such as bathing, dressing, and grooming.
• Medical Equipment: Arranging for hospital beds, oxygen equipment, and pressure-relief cushions.

8. Medication Management

Proper medication management is essential, particularly for elderly patients or those on multiple prescriptions. Keeping an updated medication list and communicating concerns to healthcare providers is crucial.

Important Steps:

• Reviewing medications, dosages, and schedules with the patient and family.
• Educating on potential side effects that could impact mobility and safety.
• Identifying medications that increase fall risk and implementing preventive measures.

9. Establishing Follow-Up Care

Post-rehab follow-up care ensures continued recovery and prevents setbacks.

Key Aspects of Follow-Up Care:

• Scheduling Appointments: Primary care visits, specialist consultations, and outpatient therapy.
• Referrals: Additional services such as outpatient PT, OT, or specialty clinics.
• Emergency Plan: Guidelines for recognizing warning signs that require immediate medical attention.

10. Emotional and Psychological Support

The transition from rehab to home can be emotionally challenging for patients and families. Anxiety, fear of falling, and frustration with limited independence are common concerns.

Support Strategies:

• Encouraging open discussions about fears and expectations.
• Providing access to mental health resources, support groups, or counseling.
• Celebrating progress to boost confidence and motivation.

11. Caregiver Resources and Support

Caregiving can be demanding, so ensuring family members have access to resources helps prevent burnout.

Available Resources:

• Respite Care: Temporary relief through in-home support or adult day programs.
• Ongoing Caregiver Training: Education on safe caregiving techniques and self-care.
• Community Support Services: Local organizations, support groups, and caregiving assistance programs.

12. Leveraging EHR Systems for Streamlined Discharge Planning

A therapy EHR system enhances discharge planning by ensuring clear communication and documentation.

Key EHR Features for Discharge Planning:

• Automated Alerts: Notifies therapists when a patient is discharged, ensuring timely completion of notes.
• Clinical Rationale for Unmet Goals: Prompts therapists to document reasons for unachieved goals, promoting transparency.
• Discharge forms that prompt therapists to enter key discharge information (e.g., end of care reason, patient discharge instructions, family discharge instructions, caregiver education, anticipated discharge destination, etc.).
• Integrated Caregiver Education: Provides built-in clinical libraries to support training and discussions.
• Printable Discharge Instructions: Ensures families receive clear, comprehensive guidance on post-rehab care.
• Satisfaction Surveys: Allows patients and caregivers to provide feedback on care quality and communication and additional support needed when the surveys are given midway through the projected timeline for discharge

Final Thoughts

Optimal discharge planning is more than a checklist - it’s a collaborative, patient-centered process that ensures a smooth transition from rehab to home or another care setting. A well-orchestrated discharge planning process, supported by progressive technology is increasingly important in today’s more complex long-term care environment.? Instituting such a process offers significant benefits to skilled nursing facilities and rehab providers that include the following:

• Enhanced patient care
• Reduction of regulatory risk and hospital readmissions
• Better cost control and efficiency
• Improved patient and family satisfaction
• Stronger facility image and referrals

By prioritizing effective discharge planning, facilities can foster better patient outcomes and build trust with their families while streamlining operations and enhancing their reputation within the community. Embracing this proactive approach ensures safer, more confident transitions and supports long-term success in an evolving healthcare landscape.

About Author:

Shraddha (like Prada) Majcher brings over 20 years of dedicated experience as a physical therapist and industry writer blending clinical insight with a knack for spotlighting progressive patient-centered care, provider empowerment, and operational excellence.