Discharge Planning and Transitions of Care: a Physical Therapist’s Perspective

By Dr. Alexis Haws, PT, DPT 

Physical therapists play an integral role in discharge planning for hospitalized patients. We are consulted to evaluate patients’ ability to perform their activities of daily living (ADLs) and safely move within their environment. This assessment of functional capacity often determines discharge disposition and post-acute care type. 

Although there are many causes for functional decline, hospitalizations remain one of the highest. Research published in the Journal of American Geriatric Society found that between 30% and 60% of older adults experience functional decline after hospitalization. For those patients, returning to the community is a complex integration of multiple considerations beyond recovered illness. Physical therapists weigh factors of current mobility, cognitive status, self-care capacity, home set-up and caregiver support when making recommendations for the most appropriate next level of care. Following these recommendations, care management teams collaborate with rehabilitation experts  to find the best-fit placement for these patients. 

However, the participation of physical therapists in transitions of care does not, and should not, stop there. We can play an even bigger role in managing both readmissions and the health system’s bottom line. It has been demonstrated that poor physical function during hospital discharge is also a robust risk factor for readmissions. Failure to improve physical function in the 30-day post-hospital window is associated with a 250 percent increase in the risk of hospital readmissions or death.¹ It becomes critical for the patients to follow a continuum of care that focuses on returning to their prior level of function or – in the mind of a therapist – a new baseline or potentially higher level of function. 

These functional outcomes are not solely predicted by the quality of intervention in the post-acute setting. Other influences include resources, social determinants of health and sealed transitions of care.  In this article, I will focus on transitions of care.  

Despite the importance of functional information in identifying those at high risk for readmissions, this information is often omitted from physician discharge summaries at high rates.² In a white paper by Jason R. Falvey, PT, DPT, GCS, PhD, clinical research fellow, he noted that information about discharge functional status, recovery trajectory, and durable medical equipment needs is often missing (in transitions of care)—even critical safety information, such as weight-bearing status, fall risk, and assistance needed with basic ambulation and transfers. He argues that physical therapists should have a seat at the table in information technology and care redesign discussions. I would add that simply having a link for post-acute care teams to pick and choose the information they receive has risks. Managed referral systems not only avoid leaking information but can reduce the non-productive time rehabilitation teams spend attempting to track down such critical information.  

Physical therapists have been mistakenly viewed by both the public and medical fields as only being “exercise experts.” That notion is antiquated and devalues our profession’s impact in reducing healthcare dollars. Our full array of skills are essential to transitions of care, reducing readmission rates, and providing better care and patient satisfaction through initiation, collaboration, and conclusion. 

1. Volpato, S., Cavalieri, M., Sioulis, F., Guerra, G., Maraldi, C., Zuliani, G., & Fellin, R. et al. (2010). Predictive value of the Short Physical Performance Battery following hospitalization in older patients. The Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 66(1): 89–96.  

2. Polnaszek, B., Mirr, J., Roiland, R., Gilmore-Bykovskyi, A., Hovanes, M., & Kind, A. (2015). Omission of physical therapy recommendations for high- risk patients transitioning from the hospital to subacute care facilities. Archives of Physical Medicine and Rehabilitation, 96(11): 1966–1972.  

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