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Madonna Rehabilitation Hospitals

Madonna’s team approach to Discharge Planning

January 13, 2021

Imagine just arriving to a rehabilitation facility to recover from a catastrophic injury and your physiatrist says to you, “It’s time to start talking about discharge planning.” You instantly think, “But I just got here! Why are we talking about discharging already?”

At Madonna, it’s our philosophy that the best discharge plans start early and involve a team approach. Even though discharge planning can be scary, intimidating and overwhelming to the patient and their family, engaging them in life-long planning early in the rehabilitation process will set the patient up for success. With proper planning, the patient should be able to successfully reintegrate into a life with purpose and meaning.

Good discharge planning can help a patient and their family rebuild a solid foundation in a time of uncertainty. Many times, these individuals are experiencing a loss of income, a loss of normalcy, role-reversals in their relationships and even a lack of access to their home or vehicle. This is why Madonna has a team of professionals guiding each patient through the discharge planning process to develop a guide on how the patient can return to his/her life roles, however different that may look.

  • Physiatrists and rehabilitation counselors are at the foundation of discharge planning: providing honest answers about the patient’s medical condition in addition to skilled intervention to help them grieve, accept and adjust to the new life that is before them with sustainable and realistic expectations.
  • Rehabilitation nurses work with a patient’s care team to discover supplies and techniques that can be used to decrease the burden of care for self-care techniques while also being good stewards of the supplies a patient may need now and into the future to stay healthy.
  • Social workers and case managers work closely with the patient on funding options, anticipating community barriers and identifying local resources that will help them access specialized follow-up services in their area to help prevent adverse health conditions that often accompany a catastrophic injury. Coordinating multiple vendors and teaching skills for managing caregivers and self-advocacy to ensure plans are sustainable and a valuable piece of the discharge plan.
  • Physical, occupational, speech, respiratory and recreational therapists consider function in the home and community and assist with emergency prep planning, in addition to identifying and introducing medically necessary equipment and technology that matches the patient’s environment and prevents secondary complications while providing opportunity for the most independence. Therapists also integrate exploring public transportation, vehicle adaptations and adaptive driving techniques, as transportation plays a key role in patients being able to access follow-up services and community resources to sustain their long-term health and wellness.

The team’s ability to anticipate barriers and to help the patient be engaged in life and follow up to sustain the gains they made in rehab and beyond should be an expectation of good discharge planning.

Discharge planning is not a list of services and equipment someone needs to safely leave the security of an inpatient setting. Instead, it should guide the patient in their transition back into the community or the least restrictive setting with the skills and supports for lifelong success and the tools needed to prevent secondary complications or adverse health conditions. The support of an expert team who will support the patient now and years to come can make all the difference.

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