Winners: Marc Brog (OTR/DOR), James Perez (OTR), Jordan Miskin (PT) and the entire Cliveden Nursing and Rehab Center team.
Brilliant Idea: Discharge Planning Starts Day 1. BETTER → FASTER → SAFER
The therapy team would meet to review each new HMO admission that has the nH Predict Outcome Report once the evaluations are completed. A realistic plan and length of stay would then be developed with the goal of enabling the patient to return home faster and safer with positive GG outcomes. The target LOS would be 12 days (or less). Attached is a sample Daily Scorecard, which was developed as a critical tool for this program, for resident tracking throughout therapy based upon a customized patient “Road to Home.”
The following areas would be reviewed by the treating therapist(s) on specific “critical” days to ensure we meet our LOS and outcome goals:
- Mobility GG
- Self-Care GG
- Cognition
- Medical Stability for in home tasks
- Nursing communication (Pain, Refusals)
- SW Communication (Equipment, D/C planning)
- Caregiver Education including home safety checklists and handouts
- Discharge Transportation
- Emergency Response System
- Client Satisfaction Survey
Supervisors and Regional Managers would monitor their GG scores on critical days throughout the stay (utilizing the attached Daily Scorecard tool). This approach would guarantee that therapists are meeting the GG goals and that residents are achieving the LOS parameters with safety and discharge planning being addressed at regular intervals throughout the stay.