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Discharge Process

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.