The discharge process begins at or before the time of admission for rehab and is evaluated throughout the stay. The case manager/rehab team seeks active patient and family involvement in this process based on individualized needs.
The following criteria are to be used in determining discharge:
- Functional inpatient rehabilitation goals are met in all therapy areas.
- No significant progress is evidenced toward functional goals.
- Goals can be addressed in a less intense program (i.e., therapy provided at non-acute inpatient setting).
- No longer needs two or more therapy services to increase functional performances.
- Appropriate discharge planning processes/follow-up care is completed based on needs assessment.
- Medical needs assessment completed and appropriate post-discharge supplies/services are coordinated.
- Patient is unable/unwilling to actively participate in inpatient rehabilitation program (3-hour rule).
- Patient no longer requires 24-hour medical or nursing supervision/treatment.
- Medically unstable - requires acute medical treatment. This will result in transfer to an acute care setting as determined by the attending physician (acute hospital admission criteria met).
- Denial of third party benefit for continued stay, unless other arrangements have been coordinated.
- Patient/caregiver trained in post-discharge program(s) as appropriate.
- Patient/family have received notification of discharge.
- Patient/family approve discharge plan.
- Appropriate level of care nursing facility placement is available.
- Nursing home pre-admission assessment completed prior to nursing facility placement.
- Against medical advice discharge.