A few months ago, on the RehabNurse Listserve, I saw this question:
“Does anyone d/c their patients in the late afternoon/evening on their last day of therapy, rather than waiting until the next morning and keeping them in the hospital overnight? If so, what challenges have you come across, if any?”
I replied:
Although the third clarification document (pg 2. question 6.) published by CMS stated:
“6. Clarification regarding the provision of therapies on the day of discharge. Generally, we do not expect patients to receive intensive therapies on the day of discharge from the IRF. However, the IRF may provide therapy on the day of discharge if the IRF believes that this is appropriate for the patient.”
The best option is to consider the needs of the patient. The time and day of discharge is important in regards to the resource needs alignment that the patient must have to return to the community. Having said that, there are other considerations as well specific to the Medicare population and the completion of the IRF-PAI document.
The requirement is to assess and score functional capability within the last three days using the discharge date to reference the three day window. The PAI manual also states that you should use a contiguous 24 hours within those last three days to capture that ‘burden of care’ measurement.
If you wait to discharge a patient on a day without therapy, you have extended your official discharge date and have limited your time frame for the discharge reference dates. If this is your practice then adopting a ‘graduation or assessment time frame’ for all staff is helpful because it improves your ability to encourage patient independence for every item possible in the discharge window (The ideal is to always enable independence for performance of all items but I understand reality and staffing can make that our largest challenge).
For Medicare patients paid on the PPS system, IS IT wise to extend the LOS (by date reference) if there is little resource benefit being provided on the day of discharge? Remember, as clinicians we are using BENEFIT DAYS of our patients. Days are limited for coverage on a yearly basis and we must be the best stewards of that time. Days spent in rehab are part A days shared with acute care for the working file count.
In summary, although clarification documents say it’s “OK” to withhold or not provide ‘intensive 3 hours’ of therapy service on the discharge day, we should consider the best options for each individual and hopefully not be prescriptive or rigid in why we make those choices.
