Inpatient and outpatient discharge: your top questions answered

One of the hardest questions for either a client or a clinician to answer is “When am I done with therapy?” Read on to check out some useful tricks and tips – and lots of questions answered! – for patients and clinicians alike to make sure that the discharge process is smooth and leaves everyone feeling confident about next steps.

What does “discharge” mean and how does it differ across settings (inpatient and outpatient)?

Discharge, or completing treatment within a specific setting or from a specific healthcare provider, is a tricky process across settings, and is impacted by so many factors. First, let’s define the process a bit.

Here are the major settings that we might be talking about getting discharged FROM. Keep in mind, this is not a straight linear model – a patient may move between these various settings throughout their journey.

In-patient Acute Care Hospital – first off, defining these settings can be tough, because they have some overlapping terminology – here I’m referring to the hospital, where a patient might have been admitted after going to the emergency department with signs of a stroke or after a traumatic brain injury.

• Who leads the discharge decision? Generally, it’s a team decision across medical providers.
• Who makes the discharge plan? Often this is completed by a case manager, who may be a nurse or social worker who has strong connections to the community and can make sure that the patient is off to the next appropriate setting for them.
• When is the patient ready for discharge? In the hospital setting, usually this is determined by medical stability and safety – doctors want you to be able to get home as soon as possible, while making sure that you’re safe to move to your next setting, wherever that might be.
• What’s next? That depends on the individual patient.  Some patients may be ready to go straight home with a referral for outpatient or home health therapy.  Some patients might need to get stronger and more independent in a skilled nursing facility.  Other patients might be ready for and need the intensive therapy that a long-term acute care hospital (an LTACH) can provide.

In-patient Long-Term Acute Care Hospital (LTACH) – these are specially designed hospitals for patients who need intensive therapy to help them recover, like speech, occupational, and/or physical therapy for about a month or more.  Patients who are a good fit for an LTACH can tolerate three or more hours of intense therapy a day.

• Who leads the discharge decision? This is also usually a team decision across medical providers, including physicians and therapists, as well as the patient and their caregivers.
• Who makes the discharge plan? Again, this is often completed by a case manager in collaboration with the rest of the care team.
• When is the patient ready for discharge? This depends on the progress that a patient made, and the therapy team’s confidence in their ability to maintain that progress and demonstrate their independence in whatever setting is next for them.
• What’s next? Again, this is patient dependent. Sometimes a patient might move from an LTACH to a skilled nursing facility if they’re not quite ready for home. Other times, a patient might go directly home from an LTACH, with referrals in place for continued outpatient or home health therapy as needed.

Skilled Nursing Facility (SNF) – a skilled nursing facility is a great fit for a patient who may not need or may not be quite ready for the intensity of an LTACH, but isn’t quite ready to be back home.

• Who leads the discharge decision? Again, a team decision is made by medical providers, but also by the patient and their caregivers to ensure that the patient will be safe when heading home.
• Who makes the discharge plan? Also a team process, generally led by a case or care manager.
• When is the patient ready for discharge? If a patient is being discharged to go home, the biggest question is whether they are ready to be home with whatever level of support is available to them.  Can they safely use the restroom on their own?  Can they safely prepare meals?  Can they manage their finances with the support they have available?  Occupational therapists are essential team members in making these decisions, because functional application of activities of daily living is their expertise.
• What’s next? Often a patient will head home after being in a SNF, or move in with a family member or other loved one.  They might continue to get support within the home, or they might transition to outpatient therapy.

Outpatient or Home Health – if the patient is medically able to be safely transported to an outpatient clinic or private practice, they might continue their therapy there.  Some outpatient clinics are a part of a hospital group, while some are private, stand-alone clinics or practices. If a patient is unable to leave the home for medical reasons, they may qualify for home health services, where the providers come to the patient to deliver therapy right in their home.

• Who leads the discharge decision? This is a team decision between the therapists, the patient, their caregivers, and sometimes primary care providers.
• Who makes the discharge plan? Usually a therapist will provide patients with discharge summaries and paperwork, which the patient and therapist can create together.
• When is the patient ready for discharge? While it may not be realistic for a patient to get back to baseline, or their ability levels before their stroke or brain injury, they may achieve the goals that they and their therapist set out at the start of therapy.  Another important thing to keep in mind is that sometimes, breaks from therapy can be helpful for patients. Therapy is hard work, and it’s important to check in from time to time to see if a break might be beneficial.
• What’s next? It’s important for patients to make sure they know what tasks and tools they should be utilizing in their everyday lives to make sure they maintain all the great progress they made in therapy.  Patients and loved ones should also be educated on red flags that suggest that they should call their therapist to see if they might need a check-in.

**Tough but important topic to mention here: in the US, sometimes the unfortunate and uncomfortable reality is that insurance coverage plays a role in these decisions. Make sure as a caregiver or patient that you ask your discharge team about insurance coverage and what to expect.  Call your insurance company and ask them what they will and won’t cover during your recovery. I won’t lie to you – it is a convoluted and challenging process. But it’s important to be an informed consumer, and the earlier you know, the better prepared you can be to cope and fight as needed.

Factors that impact discharge

A lot of components come into play when deciding whether a patient is ready to be discharged from a setting or provider:

• Medical stability – is the patient medically safe and ready to move on to a different setting or type of therapy?
• Independence – is the patient able to operate independently enough to be safe with the level of support available to them in their next setting
• Generalization – has the patient learned how to apply the skills they’ve learned in therapy across environments?

Many factors can also speed up or slow down progress to discharge, such as:

• Severity of the issue that you are being treated for
• Other medical factors & setbacks
• Frequency of visits, consistency of attendance, and participation in therapy  – this includes not only how many times per week or month a patient receives therapy, but also how consistently they make it to their appointments, ready to get to work; if you as a patient or a caregiver are having trouble physically making it to your appointments, reach out to your clinician early to brainstorm solutions.
• Ability to practice skills outside of treatment time – a patient’s practice can’t start and end as they walk in or out of a PT, OT or SLP session; if you’re a clinician looking for evidence-based homework you can easily track, check out Constant Therapy Clinician as a tool to manage your patients’ home practice programs; if you’re a patient or a caregiver, ask your clinician for homework to carry over your skills outside of therapy.

What can I do to make the discharge process smooth as a patient?

• Make your priorities known – tell your therapist what’s most important to you and remind them early and often.  Excited to read stories to your grandchildren?  Your therapist will be thrilled to help you work towards that goal!
• Ask for practice activities – practice makes progress!  Don’t limit yourself to working on your goals only during therapy – ask your therapist for tools and tips to continue that practice at home on your own time. Just a few minutes a day can make a HUGE difference. A study actually showed recently that when patients used Constant Therapy at home in addition to during sessions with their clinicians, they got MORE THAN FOUR TIMES the amount of practice!!  That adds up and results in incredible progress.
• Do the work – show up to therapy on time and ready to go, whenever you possibly can!  Therapists understand that there can be many barriers to making it to therapy – if you’re having trouble, make sure to talk with your therapist early so you can troubleshoot together.
• Take care of yourself – recovering from a brain injury or stroke, or learning to live with a new neurological disorder is an incredibly taxing experience physically, emotionally, and mentally, both for a patient and for their loved ones.  Take time to recognize those struggles and seek help from mental health providers. Give yourself grace and space to recover, adjust, and find your newly defined identity.

What can I do to make the discharge process smooth as a provider?

• Have the tough talks early – have an honest conversation with your patients early in their treatment about what they would consider a “successful outcome”. Sometimes we have to help our patients set realistic goals in the face of a completely altered life plan, and these conversations, while challenging, are essential for patients emotionally and mentally.
• Collaboratively write goals – by using patient-centered planning models, such as the Life Participation Approach to Aphasia, we can work as a team with patients and their families to define goals that are important to them, clearly stated, and thus all the more motivating.
• Track progress – there’s nothing more motivating for patients than reviewing the goals you wrote together and seeing how far they’ve come. I love to involve patients in the tracking process by asking them to rate their independence on a specific skill frequently throughout our therapy process. Constant Therapy’s progress tracking tools are also hugely helpful in reviewing concrete, data-driven speech therapy progress.
• Make discharge planning collaborative – this is especially applicable in outpatient therapy, but for many patients feeling involved in the discharge decision process is incredibly empowering.  When a life altering event like a stroke, TBI, or new neurological diagnosis occurs, a patient can feel that they’ve lost power, as do their caregivers.
• Build in a safety net – often I’ve found that making patients aware that they can always give me a call, send me an email, etc. to see if they need to return to therapy can be very comforting.  Just the knowledge that I, or another therapist, will always be here to back them up is incredibly powerful.

Finally, empower patients with tools for maintenance and continued recovery – as a clinician, giving your patients instructions on how to continue and maintain their progress on their own is hugely helpful.  Constant Therapy is a great way to do just that – our program will continue to challenge your patients using our NeuroPerformance Engine, which adjusts patient tasks based on their performance.  We also have a handy Discharge Summary within our Clinician Web Dashboard, that provides your patient with a summary of their progress within Constant Therapy and instructions on how to get set up with Constant Therapy at home.