Discharge Planning Part 2: Evaluation & Readmission Reduction

Presented by Helene Smith-Gabai and Suzanne Holm

This course describes the basic evaluation processes including formal and informal methods used in developing an OT plan of care and discharge recommendations. It also compares the different discharge planning approaches of experienced versus more novice therapists, highlighting the importance of clinical reasoning skills in formulating discharge recommendations. In addition, this course reviews the educational and equipment needs of the soon-to-be discharged patient and concludes with a discussion of the possible risk factors related to readmission and the role of OT in minimizing hospital readmission.

Meet your instructors

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Helene Smith-Gabai

Helene Smith-Gabai is currently working as an assistant professor in a master’s level occupational therapy program at Brenau University. She earned her OTD in 2004 and her Ph.D. in 2016 at Nova Southeastern University. Her dissertation study was on the discharge planning practices of occupational therapists who practice in…

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Suzanne Holm

Suzanne E. Holm, OTD, OTR/L, BCPR is a licensed occupational therapist, board certified in Physical Rehabilitation, and educator with more than twenty-five years of clinical experience in adult rehabilitation and acute care settings. She is the Occupational Therapy Academic Program Coordinator and Assistant Professor at Regis…

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Chapters & learning objectives

1. Occupational Therapy Evaluation Process and Tools in Acute Care

In making discharge recommendations that are appropriate and realistic, occupational therapists identify what the patient’s needs are, what the patient and family values and goals are, what type of support system they have, and what their prognosis and rehabilitation potential is. That’s why an understanding of the OT evaluation process is important, as it provides information that helps the therapist determine their patients’ needs. This chapter reviews the general process of OT evaluation (i.e., formal and informal methods) in the acute care setting, and how the new OT evaluation CPT codes are determined for billing purposes.

2. Identify Readmission Risk Factors and the Role of Occupational Therapy Readmission Prevention

This chapter discusses why the occupational therapy approach is effective in the prevention of post-discharge adverse events and hospital readmissions by highlighting the findings of Rogers, Bai, Lavin and Anderson’s (2016) seminal study on occupational therapy and readmission prevention.

3. Fine-Tuning the Occupational Therapy Discharge Approach: Experienced Perspectives, Equipment, and Education

Chapter three discusses the different approaches that may be taken to discharge planning between the more experienced and the more novice therapist, and how these differences guide how discharge recommendations may be formulated. A discussion of qualified therapists' reasoning processes may be helpful to better understand the overall picture and make useful discharge recommendations. This chapter also covers traditional equipment recommendations and education provided to patients and families to best prepare patients for their transition home or to another setting.

More courses in this series

Discharge Planning Part 1: Introduction to OT in Acute Care

Suzanne Holm and Helene Smith-Gabai