Discharge Planning Checklist
One of the things I hear a lot from my clients is, “I want to go home.” Sometimes I hear it during therapy sessions. Other times is comes up in a family meeting. Often, the client telling me this has cognitive deficits including deficits in safety and self-awareness.
One of the things that I’ve noticed is that these clients often ask me to give them a date. They want a specific time-frame to be given to them. I’ve found that this tends to be a problem for two reasons. First, I don’t have a crystal ball. I have a lot of experience and can make a pretty good guess about the time-frame, but I can’t guarantee where they will be at that point. Second, I want them to focus not on counting down the days but on getting more independent and safe. If they can maintain their focus on that, they often make quicker progress toward going home.
So, my approach in these situations is to help my clients develop a discharge planning checklist. We identify goals that are important to them and their family, create a list of those goals, assess their current functioning, and give them a clear goal to work toward. As a bonus, I also get to use this activity as a way to develop their functional cognition skills.
Assess prior level of functioning (PLOF) and resources/barriers to functioning; facilitate client problem solving about discharge planning; focus interventions for all disciplines; improve self-awareness
Great for 1:1 treatment
- Paper and pen or marker
- Documentation (if available) about client’s PLOF and home environment
- Phone to call caregiver or family member, if desired
- Review DC plans with DOR or SW
- Interview client and caregiver or family member and review documentation to learn about PLOF and the home environment including barriers and resources.
- Assist the client to develop a list of tasks they must be able to complete to discharge to their home. The list may include things such as walking up steps, cooking a simple meal, getting in and out of the tub, etc.
- Assist the client to assess their progress toward each goal, quantifying performance as necessary for an accurate assessment.
- Explain to the client that future interventions will focus on assessing their performance on these tasks or working to develop the skills necessary to accomplish these tasks.
- Place the list someone in the client’s room where it can be reviewed easily.
This intervention is not recommended for group or concurrent intervention. The therapist must be able to interview the client, search other sources for information about PLOF and the home environment, and facilitate patient problem solving and prioritizing.
This can happen as part of an IDT meeting or family care conference. If it does not occur during a meeting, the therapist may wish to invite a caregiver or family member to attend the session or call them as part of the session to include them in the process.
Clients may need assistance with this task depending on their self-awareness. This activity may need to be followed up by sessions which quantify the client’s current performance on the tasks identified. In this case, it may be beneficial to create a form that allow tracking client’s quantified performance over time instead of just checking off the goal as it is met.
The therapist may wish to consult other disciplines prior to completing this play to include relevant goals in the list developed. Alternately, the therapist may let other disciplines know that they have completed this intervention so that they can add goals to the list.