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Patient Discharge Decision Flowchart: Streamlining Disposition Management after Acute Hospital Stays

July 29, 2024 HMS Review

“The Hospital”, series “The Small Miseries of War” by Jacques Callot. Courtesy National Gallery of Art, Washington.

Chloe Hille [1], Rachel Brasington [1], Jaikrishan Patel [2]
[1] Nova Southeastern University, Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, Florida 33328
[2] Kansas City University College of Osteopathic Medicine, Kansas City, Missouri 64106
Correspondance: CH2063@mynsu.nova.edu


ABSTRACT
Throughout medical school, you begin to acquire a more comprehensive understanding of the appropriate approaches to patient care in various settings. While you gain expertise in the intricacies of both inpatient care and outpatient care, there is little guidance on bridging the gap between the two for patients who have recently undergone hospitalization. Since every patient has unique functional capacity and rehabilitation requirements, this process can be entirely distinct for each person. Although Case Management and Social Work teams are often responsible for making decisions on rehabilitation needs, it is our responsibility as future physicians to be knowledgeable about the available options and assist in decision-making. To this end, my colleagues and I collaborated with a team of case management specialists to design an educational handout for students, physicians, and patients that outlines and simplifies post-discharge care and rehabilitation options. This project aims to improve awareness of rehabilitation options to ensure a more seamless transition for patients who require continued care of therapies outside of the inpatient settings. We believe that this will enable providers to assist in making better informed decisions on long-term planning and encourage more personalized care.


Discharged From a Hospital Stay: What Comes Next? A Guide to Case Management

Rehabilitation Decision Aid: A Simplified Guide for Post-Discharge Care

DISCLOSURES
Funding: Not applicable.
Conflicts of interest: None.
Availability of data and materials: Not applicable.
Code availability: Not applicable.
Authors’ contributions: Authors listed in the manuscript have contributed per submission guidelines and standards for authorship.
Ethics approval: Not applicable.
Consent to participate: Not applicable. 

REFERENCES
1.          Stefanacci, R. Admission criteria for facility based post-acute services. Ann Longterm Care. 2015; 23(11). https://www.hmpg1oballearningnetwork.com/site/a1tc/articles/admission-criteria-facility-based-post-acute-services

2.          Acute inpatient rehab hospital vs. skilled nursing facility (SNF). Main Line Health. Date unknown. Accessed September 6, 2023. https://www.main1inehealth.org/specialties/rehab/inpatient/snf-vs-acute-rehab

3.          Inpatient rehabilitation care. Centers for Medicare & Medicaid Services. Date unknown. Accessed September 6, 2023. https://www.medicare.gov/coverage/inpatient-rehabilitation-care

4.          Acute inpatient rehabilitation criteria. ConnectCare. Published May, 2007. Updated March, 2020. Accessed September 5, 2023. https://www.connectcare.com/for-providers/medical-necessity-criteria/acute-inpatient-rehabi1itation/

5.          Skilled nursing facility (SNF) care. Centers for Medicare & Medicaid Services. Date unknown. Accessed March 10, 2023. https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care

6.          Van Dis, K. What is assisted living?. National Council on Aging. Published August 17, 2023. Accessed September 7, 2023. https://www.ncoa.org/adviser/local-care/assisted-1iving/

7.          Home health services. Centers for Medicare & Medicaid Services. Date unknown. Accessed March 15, 2023. https://www.medicare.gov/coverage/home-health-services

8.          O'Connor, M., Hanlon, A., Naylor, M. D., & Bowles, K. H. The impact of home health length of stay and number of skilled nursing visits on hospitalization amongMedicare-reimbursed skilled home health beneficiaries. Yes Nurs Health. 2015;58(4): 257—267. https://doi.org/10.1002/nur.21665

9.          Hospice care. Centers for Medicare & Medicaid Services. Date unknown. Accessed March 23, 2023. https://www.medicare.gov/coverage/hospice-care

10.    Teoli, D., & Bhardwaj, A. Hospice Appropriate Diagnoses. In StatPearls. StatPearls Publishing; 2023. Accessed August 24, 2023. https://www.ncbi.nlm.nih.gov/books/NBK538196/

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