Browsing by Subject "discharge planning"

Now showing 1 - 4 of 4
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    Discharge planning in acute care rehabilitation: Selecting an appropriate standardized assessment to utilize in evaluation to guide discharge recommendations
    (2025-05-05) Claybon, Anna; Hull, Kristin; Department of Occupational Therapy, School of Health and Human Sciences; Gray, Daniel; Walker, Kasey
    Effective discharge planning in the acute care setting is essential for ensuring patient safety and reducing hospital readmissions. Through a combination of a literature review, needs assessment, and clinical experience, the doctoral capstone student (DCS) identified a lack of cognitive assessment administration as a gap in current practice in the acute care setting. The purpose of this project was to identify effective cognitive assessments that support discharge planning and would allow for growth in the DCS’s understanding and administration of cognitive assessments. Based on current research and resources available, the Mini-Mental State Examination (MMSE) was examined as a tool to assess cognitive status. Through self-reflection, the DCS’s understanding of cognitive assessment administration grew over the course of the capstone experience.
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    From Hospital to Home to Participation: A Position Paper on Transition Planning Poststroke
    (Elsevier, 2019-06) Miller, Kristine K.; Lin, Susan H.; Neville, Marsha; Physical Therapy, School of Health and Rehabilitation Sciences
    Based on a review of the evidence, members of the American Congress of Rehabilitation Medicine Stroke Group’s Movement Interventions Task Force offer these 5 recommendations to help improve transitions of care for patients and their caregivers: (1) improving communication processes; (2) using transition specialists; (3) implementing a patient-centered discharge checklist; (4) using standardized outcome measures; and (5) establishing partnerships with community wellness programs. Because of changes in health care policy, there are incentives to improve transitions during stroke rehabilitation. Although transition management programs often include multidisciplinary teams, medication management, caregiver education, and follow-up care management, there is a lack of a comprehensive and standardized approach to implement transition management protocols during poststroke rehabilitation. This article uses the Transitions of Care (TOC) model to conceptualize how to facilitate a comprehensive patient-centered hand off at discharge to maximize patient functioning and health. Specifically, this article reviews current guidelines and provides an evidence summary of several commonly cited approaches (Early Supported Discharge, planned predischarge home visits, discharge checklists) to manage TOC, followed by a description of documented barriers to effective transitions. Patient-centered and standardized transition management may improve community integration, activities of daily living performance, and quality of life for stroke survivors while also decreasing hospital readmission rates during the transition from hospital to home to community.
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    Traumatic Brain Injury Discharge Planning from Inpatient Rehabilitation: A Doctoral Capstone Report
    (2025) Ridgeway, Mariah; Hull, Kristin; Department of Occupational Therapy, School of Health and Human Sciences; Showalter, Sara
    A traumatic brain injury (TBI) may have lifelong impacts on physical and psychosocial well-being, affecting patients and their support systems. Due to the complexity and variability of TBIs, determining post-discharge needs is often challenging. An interdisciplinary approach, combined with robust education and training, can aid in smoother transitions of care. However, barriers such as low health literacy and disorganized information delivery often hinder the discharge process. A multiphase needs assessment at the capstone site revealed similar gaps and barriers. The capstone student utilized the Person-Environment-Occupation-Performance model, Occupational Justice frame of reference, and Adult Learning theory to address the needs identified by the capstone site. The student provided the brain injury unit team at the inpatient rehabilitation hospital with information delivery checklists, an evidence-based resource binder, and access to a shared resource drive. Additionally, the capstone student conducted a brief educational session and collected pre- and post- survey data. Survey results confirmed the project was successful and positively impacted both the capstone student and the site.
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    What are key characteristics of adults with advanced heart failure discharged from ICU?
    (Wiley, 2024-05) Edmiston, Elizabeth A.; Hardin, Heather K.; Dolansky, Mary A.; School of Nursing
    Background As the number of people with heart failure and treatment complexity increases, many hospitals are implementing Advanced Heart Failure Intensive Care Units (AHFICU). However, little evidence concerning the clinical characteristics of people admitted to AHFICUs exists. Understanding the clinical characteristics of people admitted to the AHFICU will assist nurses with implementing tailored interventions to ensure high-quality care delivery. Aim The purpose of this study was to describe the clinical characteristics of people who are admitted to and discharged from an AHFICU. Study Design Baseline data from a longitudinal descriptive study were collected on adults (N = 43) admitted to an AHFICU. Heart failure severity, self-management ability, cognition, sleep quality, and other clinical characteristics were assessed. Results Most study participants were New York Heart Association functional class IV (n = 24) or class III (n = 14), indicating poor functional capacity. Over half had mild cognitive impairment and poor sleep quality was prevalent (92.7%). Participants had adequate levels of heart failure knowledge, but low levels of heart failure self-management decision-making and ability. Conclusions Interventions to address the unique clinical characteristics of AHFICU patients include sleep hygiene, integration of cognitive, sleep, and self-management assessments into the electronic medical record. Addressing the unique clinical needs of people with heart failure will lead to patient-centered, evidence-based, and safe care.