Wednesday, June 15, 2016 From PTJ: PT Input Key to Reducing Hospital Readmissions Although a number of new models of care have emerged to decrease hospital readmissions in Medicare patients, they "do not adequately address functional deficits," say the authors of a recent "Perspectives" article e-published ahead of print in Physical Therapy (PTJ), APTA’s science journal. Experts note that "hospital readmission rates after acute care discharge are 3 times higher if physical therapist (PT) discharge recommendations are replaced with less intensive interventions," yet the current care transition models do not formally include PTs in assessing or treating any functional impairments or risk factors. So what does the "ideal transition of care" look like? Authors provide several recommendations for involving PTs to "bridge the treatment gap between hospital discharge and outpatient follow-up." Here are a few: One-on-one communication between providers is essential. Discharge planning should allow more time for "synchronous" communication between acute care PTs and community-based outpatient or home health PTs. One-on-one communication could ensure that the community provider can see the patient, understands the patient’s specific needs, and "has the requisite expertise" to treat the patient’s condition. Don’t wait until discharge to educate the patient. By educating patients about follow-up care throughout their hospital stays, the acute care PT can ensure the patient and caregiver understand the instructions, as well as address any barriers to following them. Patients also need to know if and when to seek physical therapy, if it is not necessary upon discharge. Involve patients and caregivers in discharge planning. According to research, authors write, when patients are involved in their discharge planning "there is a decreased risk of 30-day readmissions." Including caregivers can help them manage limitations while they recover, and determine whether a skilled caregiver is needed. PTs should document the patient’s functional recovery, discharge status, and "trajectory of recovery," and ensure that the information is transferred to community providers upon discharge. This will greatly assist PTs and physicians in evaluating risk factors for rehospitalization. Acute care PTs can help their facilities develop methods and templates for communicating this information in a clear, organized manner. Acute care PTs should be involved in advance care planning. A surprising 50% of older adult palliative care patients experience impairment-related falls. A PT can advocate for preventive or maintenance physical therapy in discussions with a hospice or palliative care team. Monitor functional recovery, not just medical symptoms. Current models of care do not formally include monitoring physical function after discharge. PTs can contribute by establishing common assessment tools and monitoring recovery. They also can educate community-based physicians and nurses about "key self-reported functional deficits" and medical symptoms, such as dizziness, that could interfere with activities of daily living and potentially lead to readmission. Routinely assess physical function at follow-up. PTs can help develop assessment batteries for community physicians to administer, with "functional cut-offs" indicating risk for rehospitalization. The Stopping Elderly Accidents, Deaths, and Injuries (STEADI) falls-risk assessment tool is an example. With these recommendations, authors hope to "start a conversation about how we shift the rehabilitation paradigm in acute care settings away from a distinct ‘silo’ of care that ends when the patient leaves the hospital toward a model where acute care physical therapists extend their plan of care to include the 30-day transitional care period during which hospitals remain accountable for patient outcomes." Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.