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Flashcards in Referrals And DC Planning Deck (20):
1

Important to know

Baseline/previous functional level

Change is status - why is there a change in status from baseline?

2

DC potential members of the team

MD
Nursing
Case manager
PT, OT, ST
RT
RD
Social work
Others
Pt family/support system

3

D/C destination factors

Current level functioning compared to PFL

Support system

Living situation

Insurance

Safety

4

Where will pts be distracted to from acute?

Home - I or w/ fam

Home w/ out pt PT

Home with home PT

Inpt rehab

TCU

ECF/SNF

Hospice

5

Centers of care

Facilities that specialize in specific conditions

Ie MS, Parkinson’s CVA

6

Transitional care unite/ long term acute

Pt requires SN care

Focus: medical manage of chronic condition

Pt not ready for intensity of acute rehab

Length of stay

7

TCU/long term therapy provided

Less than 3 hours/day for 5-6 days/ week

8

Long term care / SNF

Pt unable to be cared for a home and needs assistance w/ daily tasks

Pts is medically stable

May be step toward acute rehab

Team approach idea w/ therapies involved

Pt care may be coordinated by a nurse and MD

9

SNF therapy is provided

30-60 mins/ day
Frequency may vary

10

Assisted living facility

Between retirement home and SNF

Residents have certain criteria they must meet to reside here:

-medically table. May have chronic condition as long as managed and under control
-only requiring min A for ADLS
-primarily needing this type of living arrangement for safety
-once increased care or assistance is required, they may transfer to an extended care facility

11

Acute rehab

Pt is in need of continued INTENSIVE rehab

Rehab nurses of staff

Rehab team hold weekly meetings to review case

Pt care is coordinate through a case manager

12

Acute rehab - therapy

Pt must tolerate at least 3 hours of therapy/day for 5-7 days/ week

May include PT, OT, ST, recreational therapy

13

Home health therapy

Pt is home, medically stable w/ proper resources for care

Must be “home bound” - inability to get transportation anywhere

Require skilled services

Strong social support

Paid my Medicare, commercial insurance, private pay

May be a step toward out pt therapy

14

Outpatient clinic

Pt is living at home - has transportation to/from clinic

Nursing services are typically not included

Paid by Medicare, commercial insurance, out of pocked

15

Outpatient clinic - therapy

Provided 2-3 times per week

16

Going home/ family training - ID right person to train

Physical ability
Cognitive ability
Do they care?

17

Readying the family to assist the pt in going home

Functional mobility
Equipment

18

Family training - designated person should be

-safe and I w/ assisting pt with all of their needs related to PT
-capable of learning
-receptive to your input/instructions
-cognizant of their own body mechanics


**needs to be able to reverse demonstrate to the PT all that is required to be safe

19

PT role in D/C planning

Good understanding of pt’s PFL

Pt’s level of function at time of d/c

DME recommendations

Communication

20

Transitional living center

Some acute rehabs have a transitional place for patients getting ready to leave acute rehab

Stay of leave is longer

Insurance does have a play in this