Patient Discharge Decision Flowchart: Streamlining Disposition Management after Acute Hospital Stays
DOI:
https://doi.org/10.65539/9731c232Keywords:
hospital discharge, post-acute care, rehabilitation, case management, medical educationAbstract
Transitions from inpatient to post-acute care are complex and often confusing for trainees, clinicians, and patients. This perspective describes the development of a visual discharge decision aid created in collaboration with case management specialists to clarify rehabilitation and post-acute care options after hospitalization. The flowchart outlines criteria for long-term acute care hospitals, acute inpatient rehabilitation, skilled nursing facilities, assisted living, home health, and independent discharge. By improving awareness of functional status requirements, intensity of services, and typical patient trajectories, the tool aims to support more informed, patient-centered disposition planning and help trainees better understand the continuum of post-acute care.
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References
Stefanacci R. Admission criteria for facility based post-acute services. Ann Longterm Care. 2015;23(11). Available at: https://www.hmpgloballearningnetwork.com/site/altc/articles/admission-criteria-facility-based-post-acute-services
Acute inpatient rehab hospital vs. skilled nursing facility (SNF). Main Line Health. Accessed September 6, 2023. Available at: https://www.mainlinehealth.org/specialties/rehab/inpatient/snf-vs-acute-rehab
Inpatient rehabilitation care. Centers for Medicare & Medicaid Services. Accessed September 6, 2023. Available at: https://www.medicare.gov/coverage/inpatient-rehabilitation-care
Acute inpatient rehabilitation criteria. ConnectCare. Published May 2007. Updated March 2020. Accessed September 5, 2023. Available at: https://www.connectcare.com/for-providers/medical-necessity-criteria/acute-inpatient-rehabilitation/
Skilled nursing facility (SNF) care. Centers for Medicare & Medicaid Services. Accessed March 10, 2023. Available at: https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care
Van Dis K. What is assisted living? National Council on Aging. Published August 17, 2023. Accessed September 7, 2023. Available at: https://www.ncoa.org/adviser/local-care/assisted-living/
Home health services. Centers for Medicare & Medicaid Services. Accessed March 15, 2023. Available at: https://www.medicare.gov/coverage/home-health-services
O’Connor M, Hanlon A, Naylor MD, Bowles KH. The impact of home health length of stay and number of skilled nursing visits on hospitalization among Medicare-reimbursed skilled home health beneficiaries. Nurs Health. 2015;58(4):257–267. doi:10.1002/nur.21665 DOI: https://doi.org/10.1002/nur.21665
Hospice care. Centers for Medicare & Medicaid Services. Accessed March 23, 2023. Available at: https://www.medicare.gov/coverage/hospice-care
Teoli D, Bhardwaj A. Hospice Appropriate Diagnoses. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2023. Accessed August 24, 2023. Available at: https://www.ncbi.nlm.nih.gov/books/NBK538196/
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Copyright (c) 2024 Chloe Hille, Rachel Brasington, Jaikrishan Patel (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
