Discharge Planning Guidelines - GTA Rehab Network

1 Discharge Planning Guidelines FOR INPATIENT REHABILITATION. The Discharge Planning Guidelines for Inpatient Rehabilitation have been developed by the GTA Rehab Network 's Patient Access and Flow Committee to promote effective, efficient and consistent Discharge Planning processes in inpatient active/regular stream and Low Tolerance Long Duration/slowstream rehabilitation. These Guidelines include 3 sections: Section 1: ALC in Rehab Definition Section 2: Discharge Readiness Indicators Section 3: Discharge Planning Considerations The Discharge Planning Guidelines for Inpatient Rehabilitation are supported by the following guiding principles and timeframes.

2 Discharge Planning Guiding Principles and Standards Guiding Principles Assessment, treatment and Discharge Planning is an ongoing iterative process conducted throughout the admission period There are established mechanisms for the development and communication of goals and plans with each patient/family The identification of Rehab goals takes into account that rehabilitation can continue throughout the care continuum and as such, Rehab goals specific to the inpatient setting are identified and documented through a collaborative process with the patient/family.

3 Standards Within 7 days of admission, determine an estimated date of Discharge and provisional destination. Within 7 days of admission, screen for factors that may delay Discharge and develop a plan of care for addressing the identified barriers to Discharge . For the patient in an active Rehab program who has been identified as at risk for delayed Discharge , schedule the first patient/family team meeting by the second week of admission. For patients in LTLD/slowstream Rehab who are at risk for delayed Discharge , schedule the first patient/family team meeting within 4-6 weeks of admission.

4 Conduct weekly team meetings to promote consistency in the treatment approach by identifying and reviewing the patient's care plan, treatment goals, progress and Discharge plans. Throughout the admission, consider the Discharge readiness indicators and determine appropriate timing for ALC. designation. Discharge ready from Home Assess / Treat inpatient Admit CCC. (active/LTLD) Rehab = ALC Designation LTC. Discharge Planning July 2009. SECTION 1: PROVINCIAL ALTERNATE LEVEL OF CARE (ALC) DEFINITION. PROVINCIAL ALTERNATE LEVEL OF CARE (ALC) DEFINITION.

5 For implementation in all acute and post-acute hospitals*. (Adapted from the Wait Time Information Strategy). Provincial ALC Definition Note 1. The healthcare system aspires to deliver care in a setting that is The patient's care goals have been met or congruent with the clinical needs of a patient as defined by the progress has reached a plateau or patient's health status, treatment plan and goals. the patient has reached her/his potential in that program/level of care or an admission occurs for supportive care because the services are not The definition applies to all patient populations waiting in all accessible in the community ( social admission ).

6 Patient care beds in an acute or post acute care hospital in This will be determined by a physician/delegate, in collaboration with an Ontario. interprofessional team, when available. Note 2. Discharge /transfer destinations may include, but are not limited to: Definition: home (with/without services/programs), rehabilitation (facility/bed, internal or external), When a patient is occupying a bed in a hospital and complex continuing care (facility/bed, internal or external), does not require the intensity of resources/services transitional care bed (internal or external), provided in this care setting (Acute, Complex long term care home, Continuing Care, Mental Health or Rehabilitation)

7 , the group home, patient must be designated Alternate Level of Care convalescent care beds, 1. (ALC) at that time by the physician or her/his delegate. palliative care beds, The ALC wait period starts at the time of designation retirement home, and ends at the time of Discharge /transfer to a shelter, 2. Discharge destination (or when the patient's needs or supportive housing. condition changes and the designation of ALC no longer applies). This will be determined by a physician/delegate, in collaboration with an interprofessional team, when available.

8 Final Note The definition does not apply to patients: waiting at home, waiting in an acute care bed /service for another acute care bed/service ( , surgical bed to a medical bed), waiting in a tertiary acute care hospital bed for transfer to a non tertiary acute care hospital bed ( , repatriation to community hospital). *as of July 1, 2009. July 2009 2. SECTION 2: Discharge READINESS INDICATORS. Patients whose medical and functional status has improved in inpatient Rehab are ready for Discharge to the community when.

9 Medical Stability: Suggested measurement tools: Vital signs stable and Vital Signs: As determined by MD. Hemodynamically stable and Lab work within accepted ranges and Lab Work: Completed before Discharge and ongoing requirements for lab work can be met in the All necessary/urgent medical consults and tests have been performed and community Considerations Pain is well-controlled ( patient is able to manage pain independently or with the assistance of a pain management clinic) and Pain Management: As determined by established for current care Established and managed bowel & bladder routine and pain management scales ( Visual Analog Scale, A.)

10 Numerical Rating Scale) (See Appendix A and B). needs Established medication management and practices and L. Nursing/MD Requirements: Patient/caregiver/family demonstrates effective C. 24 hour specialized skill nursing care is not required and management of bowel & bladder routine On-site access to MD is not required and Patient may or may not require home-based nursing ( wound care, IV) or other health Patient/caregiver/family demonstrates effective medication management professional services D. and Rehab Goal Attainment:2 Suggested measurement tools: E.