Discharge from a SNF to the community requires the successful transfer of information from care providers to the patient and family to ensure optimal outcomes, reduce adverse events, and prevent unnecessary hospital readmissions. Preparing the patient and family to be an active partner in the transition planning helps ensure they are prepared and can make necessary arrangements. The process of safe transition planning begins upon admission and evolves based on changing needs.

Benefits of using the Functional Pathways Safe Transition Planning Tool

  • Provides a standardized procedures to reduce variation & eliminate transition delays
  • Helps achieve appropriate functional outcomes needed for safe transition to next level of care
  • Helps achieve appropriate length of stay for safe transition to next level of care
  • Helps Reduce avoidable re-hospitalizations
  • Enhances patient engagement & experience resulting in measurable improvements in safety and qualityGoal Setting According to Transition Plan:
Ø  Destination: assisted living, home, SNF Ø  Destination barriers: stairs, tub, carpet
Ø  Caregiver assist: 24-hr, intermittent, none Ø  Equipment: already owns vs. needs

Prioritize Treatment Focus:

  • Basic mobility: ambulation, transfers, bed mobility
  • Self-care ADLs: self-feeding, bathing, dressing, toileting
  • IADLS: needs vary depending on caregiver assist
  • Safe swallowing: training on strategies, proper preparation of altered diet
  • Cognition: assessment of cognition, medication management, safety for ADLs and basic mobility
  • Patient/caregiver education – must be timely and relevant
  • Patient and caregiver education
  • Complete home ADL assessment
  • Every treatment encounter must be focused and clinically sophisticated

Plan Safe Transition with Interdisciplinary Team

    • Identify equipment needs
    • Recommend medically necessary follow-up care
    • Complete patient and caregiver teaching and training
    • Collaborate with follow-up care providers (home health, outpatient therapy) – what info is meaningful to them?

Melissa Ward

Director of Clinical Services