Research Report

Physical Therapists Make Accurate and

Appropriate Discharge
Recommendations for Patients
Who Are Acutely Ill
Beth A. Smith, Christina J. Fields, Natalia Fernandez
B.A. Smith, PT, DPT, PhD, is Post-
doctoral Fellow, Balance Disorders
Background. Acute care physical therapists contribute to the complex process Laboratory, Departments of Neu-
of patient discharge planning. As physical therapists are experts at evaluating func- rology and Behavioral Neuro-
tional abilities and are able to incorporate various other factors relevant to discharge science, Oregon Health and
planning, it was expected that physical therapists’ recommendations of patient Science University, Portland, Ore-
discharge location would be both accurate and appropriate. gon. During the data collection
for this project, she was a PhD
candidate in the Developmental
Objective. This study determined how often the therapists’ recommendations Neuromotor Control Laboratory,
for patient discharge location and services were implemented, representing the School of Kinesiology, University
accuracy of the recommendations. The impact of unimplemented recommenda- of Michigan, and a per diem staff
tions on readmission rate was examined, reflecting the appropriateness of the member, Division of Physical
Therapy, University of Michigan
recommendations.
Hospital, Ann Arbor, Michigan. In-
stitutional mailing address: NSI,
Design. This retrospective study included the discharge recommendations of 40 OHSU West Campus, 505 NW
acute care physical therapists for 762 patients in a large academic medical center. The 185th Ave, Beaverton, OR 97006
frequency of mismatch between the physical therapist’s recommendation and the (USA). Address all correspondence
to Dr Smith at: smitbeth@
patient’s actual discharge location and services was calculated. The mismatch vari-
ohsu.edu.
able had 3 levels: match, mismatch with services lacking, or mismatch with different
services. Regression analysis was used to test whether mismatch status, patient age, C.J. Fields, PT, MPT, is Physical
Therapy Clinical Specialist, Car-
length of admission, or discharge location predicted patient readmittance.
diovascular Team, University of
Michigan Hospital.
Results. Overall, physical therapists’ discharge recommendations were imple-
mented 83% of the time. Patients were 2.9 times more likely to be readmitted when N. Fernandez, PT, Master of
Health Science (Physical Therapy),
the therapist’s discharge recommendation was not implemented and recommended is Staff Physical Therapist, Cardio-
follow-up services were lacking (mismatch with services lacking) compared with vascular Team, University of
patients with a match. Michigan Hospital.

[Smith BA, Fields CJ, Fernandez N.

Limitations. This study was limited to one facility. Limited information about the Physical therapists make accurate
patients was collected, and data on patient readmission to other facilities were not and appropriate discharge recom-
collected. mendations for patients who are
acutely ill. Phys Ther. 2010;
90:693–703.]
Conclusions. This study supports the role of physical therapists in discharge
planning in the acute care setting. Physical therapists demonstrated the ability to © 2010 American Physical Therapy
make accurate and appropriate discharge recommendations for patients who are Association
acutely ill.

Post a Rapid Response to

this article at:
ptjournal.apta.org

May 2010 Volume 90 Number 5 Physical Therapy f 693

Downloaded from https://academic.oup.com/ptj/article-abstract/90/5/693/2737769
by guest
on 11 January 2018
 Acute Care Physical Therapists’ Discharge Recommendations
D
ischarge planning is the de-
velopment of a discharge plan
for follow-up services for a pa-
tient prior to leaving the hospital,
with the aim of containing costs and
improving patient outcomes.1 Dis-
charge planning is a complex pro-
cess, and many health care disci-
plines may contribute to the plan,
including formal discharge planning
coordinators, nurses, social workers,
physical therapists, occupational
therapists, and physicians. Reviews
of discharge planning processes
showed that they consistently in-
volve the assessment of many fac-
tors, including cognitive, physical
and social/financial status, environ-
mental concerns, and access to for-
mal and informal care.2,3
In an effort to assess these many fac-
tors, formal discharge planning in
the United States often is practiced
as a collaborative, multidisciplinary
effort led by a case manager, partic-
ularly for patients identified as hav-
ing an increased risk for poor out-
comes.4,5 Although the shift toward
collaborative discharge planning has
improved patient outcomes, there
remains room for further improve-
ment. A study by Mamon and col-
leagues6 showed that multidisci-
plinary discharge planning efforts
led by formal case managers ap-
peared to be significantly more effec-
tive in arranging home nursing care
and rehabilitation services than infor-
mal discharge planning; however,
Available With
This Article at
ptjournal.apta.org
• Discussion Podcast: Participants
to be determined.
• The Bottom Line Podcast
• Audio Abstracts Podcast
This article was published ahead of
print on March 18, 2010, at
ptjournal.apta.org.
694 f Physical Therapy Volume 90
Downloaded from https://academic.oup.com/ptj/article-abstract/90/5/693/2737769
by guest
on 11 January 2018
patients still often reported these
and other needs were unmet after
discharge. The study did not exam-
ine how the discharge planning pro-
cess failed to accurately identify or
meet the needs of the patients, but as
many health care professionals par-
ticipate in the multifactorial process,
the final decision on discharge place-
ment may not take into consider-
ation each professional’s recommen-
dation. Important information from
one discipline may be overlooked or
excluded from the final discharge
plan, leading to failure of the plan.
Poor discharge planning and the fail-
ure to provide necessary services
may have an impact at several levels:
failure of the patient to reach opti-
mal health and functional status, in-
creased cost to the hospital and de-
creased resource availability to
others due to increased length of
stay and readmission, or possible ad-
verse events or conditions causing
harm to the patient.7 In an effort to
better understand failure of the plan,
several factors have been associated
with poor postdischarge outcomes:
aged 80 years and older; inadequate
support system; multiple, active,
chronic health problems; history of
depression; moderate to severe func-
tional impairment; multiple hospital-
izations during the prior 6 months;
hospitalization within the past 30
days; fair or poor self-rating of
health; or history of nonadherence
to the therapeutic regimen.7
It is clear from the large number
and broad nature of factors associ-
ated with poor discharge outcomes
that discharge planning is a com-
plex process requiring the assess-
ment and assimilation of multiple
factors. Additional evidence of dis-
charge planning as a complex pro-
cess is the lack of use of standardized
quantitative measures to determine
discharge recommendations. De-
spite the validation of measures such
as the Berg Balance Scale to predict
Number 5
discharge disposition,8 physical ther-
apists and hospitals do not rely solely
on standardized tests in regard to dis-
charge planning.9,10 Standardized
screening forms are often used to
identify patients at high risk of poor
outcomes in order to initiate the for-
mal multidisciplinary discharge plan-
ning process, but they are not used
to make the decision on discharge
location and services.3,5,6,11
The need for comprehensive assess-
ment of functional status is one fac-
tor in discharge planning that is di-
rectly related to the practice of
physical therapy. One study quanti-
fied change in functional status, re-
porting that 35% of patients aged 70
years and older showed a decline in
activities of daily living function be-
tween hospital admission and dis-
charge.12 Patients experiencing a de-
cline in functional status while in the
hospital may no longer be able to
function adequately in the environ-
ment they lived in prior to admis-
sion, and are less likely to recover
baseline function and health status.13
There is an association between de-
creased functional status and trans-
fers to and from acute care set-
tings.14 There also is an association
between decreased functional status
and complicated posthospital care
transitions.15
The studies described above show
that level of functional ability is re-
lated to discharge location; however,
other studies demonstrate that the
relationship, consistent with the
theme of discharge planning, is com-
plex. Although patients returning
home had a higher level of function
than those who were discharged
elsewhere, some patients who were
significantly impaired returned
home with family support. Patients
who had family support but were
discharged to facilities were the
most impaired.8 Additionally, re-
searchers studying the effect of func-
tional level on length of hospital ad-
May 2010

mission found that patients with a
higher level of function demon-
strated a shorter length of stay than
average, but patients with a low level
of function who were discharged to
a supportive environment also had a
shorter-than-average length of stay.16
These findings highlight the com-
plex relationship between functional
ability and discharge needs and fur-
ther support physical therapist eval-
uation of functional abilities, assis-
tance required for safety, and
recommendations for discharge loca-
tion based on what the patient re-
quires and what is available to them.
Physical therapists in the acute care
setting play an important role in the
multidisciplinary discharge planning
process. “Discharge to the appropri-
ate level of care” often is a goal in
acute care physical therapy,17 and
therapists routinely make recom-
mendations regarding discharge
placement and any continuing ther-
apy services for patients. Due to
short average lengths of admission in
acute care, patients often need con-
tinued physical therapy services af-
ter leaving acute care, and therapists
may recommend that continued ser-
vices take place in the home, a
skilled nursing facility (SNF), a reha-
bilitation center, or an outpatient
setting.18
Although creating a discharge plan is
a multidisciplinary process, physical
therapists practicing in acute care
are in a unique position to assess the
discharge needs of a patient. This is
well described within the scope of
practice in the Guide to Physical
Therapist Practice: “The plan of care
identifies anticipated goals and ex-
pected outcomes, taking into consid-
eration the expectations of the
patient/client and appropriate oth-
ers. . . . The plan of care includes the
anticipated discharge plans. In con-
sultation with appropriate individu-
als, the physical therapist plans for
discharge and provides for appropri-
May 2010
Downloaded from https://academic.oup.com/ptj/article-abstract/90/5/693/2737769
by guest
on 11 January 2018
Acute Care Physical Therapists’ Discharge Recommendations
ate follow-up or referral.”19(p46) Fur- disability, patients’ wants and needs,
thermore, physical therapists are patients’ ability to participate in
health care professionals who diag- care, and patients’ life context. The
nose and treat individuals of all ages therapists gathered and integrated
who have medical problems or other information from multiple con-
health-related conditions that limit structs before making their dis-
their ability to move and perform charge recommendation, showing
functional activities in their daily consideration of what the patients
lives,19 and the assessment of func- required and what was available in
tional abilities is a particularly impor- their environment.9
tant and complex aspect in deter-
mining discharge needs. Building upon previous descriptions
of the complexities of the decision-
Having established that physical making process and the idea that
therapists are well qualified to par- physical therapists are uniquely
ticipate in the complex discharge suited to contribute useful insight
planning process, how do they come through their evaluation and assess-
to a decision on a discharge recom- ment skills, we wanted to validate
mendation? According to a qualita- the participation of acute care phys-
tive study by Jette et al,9 physical ical therapists in the discharge plan-
therapists appeared to use a patient’s ning process. Because we hypothe-
level of functioning and disability as sized that therapists are able to
the core dimension in their initial successfully incorporate all of the
decision-making process. In general, various factors involved in the dis-
they were guided by 4 constructs charge planning process and that
when making a discharge recom- there is value placed on the thera-
mendation: patients’ functioning and pist’s recommendation by the final
The Bottom Line
What do we already know about this topic?
Acute care discharge planning is a complex process that involves clini-
cians from varied disciplines and the assessment of many factors. Physical
therapists often are involved in discharge planning and make recommen-
dations for follow-up services, but the accuracy and appropriateness of
their recommendations have not been studied.
What new information does this study offer?
This study indicates that physical therapists are able to integrate multiple
patient factors to make accurate and appropriate discharge recommen-
dations. When the physical therapist’s recommendation was not imple-
mented and follow-up services were lacking, patients were more likely to
be readmitted to the hospital.
If you’re a patient, what might these findings mean
for you?
If you are in the hospital and have any concern that you will not be fully
functional at discharge, you should seek a physical therapist’s recommen-
dation for the most appropriate discharge destination.
Volume 90 Number 5 Physical Therapy f 695
 Acute Care Physical Therapists’ Discharge Recommendations
discharge plan decision maker, we
anticipated that the therapist’s dis-
charge recommendations for pa-
tients in the acute care setting would
match the patient’s actual discharge
location and services a majority of
the time. Furthermore, supporting
the idea that therapists are appropri-
ate in their recommendations, we
expected an increased likelihood of
hospital readmissions when recom-
mendations were not implemented.
Method
The University of Michigan Hospital
is a 700-bed acute care teaching hos-
pital. Our facility is a level 1 trauma
center offering and receiving heli-
copter transfers for patients from
Michigan and its surrounding states
who are in critical and complex sit-
uations; many of our patients are
transferred from outside hospitals
for ongoing care.
Discharge Planning Process
The discharge planning process in
our facility occurs in a fairly, but not
completely, standardized manner.
The initial parts of the process are
standard; practice management co-
ordinators use a screening form
based on the factors associated with
poor discharge outcomes to screen
all admitted patients and identify
those who are at increased risk for
poor discharge outcomes. Patients
who are not identified as high risk by
the screening process have dis-
charge planning done by their staff
nurse, unless formal discharge plan-
ning is later requested. For patients
who are identified as high risk, for-
mal discharge planning is initiated,
with practice management coordi-
nators taking the lead role in the
discharge planning process. They read
the documentation on discharge
recommendations from the physical
therapist evaluation and any sub-
sequent physical therapist docu-
mentation and incorporate it into a
multidisciplinary discharge planning
process, including any documenta-
696 f Physical Therapy Volume 90
Downloaded from https://academic.oup.com/ptj/article-abstract/90/5/693/2737769
by guest
on 11 January 2018
tion they read from the medical/sur-
gical team, unit nurses, and, when
consulted, occupational therapists
and social workers. In this basic pro-
cess, the coordinator may or may not
seek additional information from
other members of the health care
team. If a consensus has been iden-
tified, the coordinator proceeds to
arrange insurance benefits and nec-
essary services. If there is not a con-
sensus, the coordinator will elicit ad-
ditional information from the other
members of the health care team,
usually using the hospital alphanu-
meric paging and telephone systems.
A lack of consensus can occur, for
example, if the patient’s preferences
change or if insurance benefits are
not available.
Physical therapist involvement in the
discharge planning process starts
when the medical/surgical team
sends an electronic consult to the
Division of Physical Therapy through
our online medical charting system.
The therapist does an initial evalua-
tion, with the exact procedures vary-
ing according to the ability of the
patient to participate. The overall
process is best described in the Guide
to Physical Therapist Practice:
[Physical therapists] engage in an ex-
amination process that includes tak-
ing the patient/client history, con-
ducting a systems review, and
performing tests and measures to
identify potential and existing prob-
lems. To establish diagnoses, prog-
noses, and plans of care, physical
therapists perform evaluations, syn-
thesizing the examination data and
determining whether the problems to
be addressed are within the scope of
physical therapist practice. Based on
their judgments about diagnoses and
prognoses and based on patient/cli-
ent goals, physical therapists provide
interventions (the interactions and
procedures used in managing and in-
structing patients/clients), conduct
reexaminations, modify interventions
as necessary to achieve anticipated
goals and expected outcomes, and de-
Number 5
velop and implement discharge
plans.19(p21)
The physical therapist documents his
or her evaluation in the computerized
patient medical record. At the top of
every therapist evaluation and any sub-
sequent documentation, information
is highlighted that is particularly rele-
vant to discharge recommendations,
specifically therapist recommenda-
tions for discharge location, the
amount of assistance required for pa-
tient safety, necessary assistive de-
vices, and the need for ongoing phys-
ical therapy and the appropriate
setting. This information is consis-
tently provided by therapists, regard-
less of whether or not patients are re-
ceiving formal discharge planning.
Follow-up physical therapy treatments
are provided as appropriate through-
out the patient’s acute care stay, and
discharge recommendations are up-
dated and documented each time a
therapist works with the patient.
Although all physical therapist rec-
ommendations are consistently doc-
umented in the medical record in a
standard manner, the remaining dis-
charge process varies in how com-
munication is exchanged. Beyond
the basic discharge planning pro-
cess, some service areas of the hos-
pital follow additional procedures
that increase in-person communica-
tion between health care providers.
Three of the services hold additional
daily or weekly “discharge rounds”
interdisciplinary meetings, attended
by the resident physician, practice
management coordinator, occupa-
tional therapist, physical therapist,
and social worker. In addition, some
coordinators work with 1 or 2 spe-
cific services and make it a point to
meet in person with the therapists,
whereas other coordinators float
among services and do not do so.
Data Collection
To conduct our retrospective study
of the outcomes of the discharge
May 2010

planning process, we obtained Uni-
versity of Michigan Privacy Board
approval for waiver of informed
consent to access patient medical
records and institutional review
board approval for the use of physi-
cal therapists as human participants.
We accessed the medical records of
all patients who received a physical
therapist evaluation during our study
period. We also collected data about
career history from consenting ther-
apists to further describe therapist
practice at our facility.
We created a secure database and
separated identifying information
about patients and therapists from
de-identified, coded data collection
forms. We selected one week (Sun-
day–Saturday) in each season of the
preceding year. The weeks were in
December 2007 and March, June,
and September 2008 and did not in-
clude any holidays.
Two research assistants were
trained, using case studies, to access
medical records and find the rele-
vant information and enter it into the
database. Information was collected
primarily from physical therapist
evaluations and treatment notes,
physician discharge notes, and prac-
tice management coordinator evalu-
ations and notes. Occasionally, data
were found in emergency depart-
ment documentation, physician ad-
mitting history and physical docu-
ments, social work notes, nursing
notes, and outpatient or rehabilita-
tion facility documentation from our
health system. Any questions related
to data collection were resolved by
consensus of the 3 primary investi-
gators (B.A.S., C.J.F, and N.F.).
Variables and Inclusion Criteria
We identified 51 physical therapists
who were working in acute care dur-
ing our selected weeks. Forty out of
the possible 51 therapists consented
to participate in our study. The 11
therapists who were not included
May 2010
Downloaded from https://academic.oup.com/ptj/article-abstract/90/5/693/2737769
by guest
on 11 January 2018
Acute Care Physical Therapists’ Discharge Recommendations
were those we could not contact,
who were no longer employed at the
university, or who were temporary
staff who did not evaluate patients
during the 4 weeks we analyzed.
One of the 3 primary investigators
discussed the study with each thera-
pist before the informed consent
form was signed. After consent, par-
ticipating therapists were asked to
provide the following background
information: total months of practice
as an acute care physical therapist,
total months and setting of other,
nonacute care physical therapist ex-
perience, and total months of prac-
tice as an acute care physical thera-
pist at University of Michigan
Hospital.
We used hospital billing records to
identify that 780 patients received a
physical therapist evaluation during
our specified 4 one-week periods,
and we included all of them in our
study. We specified the following
operational definitions and collected
the following data from patient med-
ical records:
• Age of patient, in years.
• Patient’s primary service at dis-
charge—service team of attending
physician at the time of discharge,
listed by abbreviation code.
• Date of admission, in MM/DD/YYYY
format.
• Date of discharge, in MM/DD/YYYY
format.
• Date of physical therapy evaluation, in
MM/DD/YYYY format.
• Discharge location—the physical loca-
tion the patient was sent to at the end
of the hospital admission, coded as
home without physical therapy, home
with outpatient therapy, home with
home therapist, subacute rehabilita-
tion/SNF, acute rehabilitation, ex-
tended care facility without therapy,
or expired.
• Physical therapist at discharge—phys-
ical therapist identifier code of the
Volume 90
therapist who documented the final
discharge recommendation.
• Physical therapist discharge recom-
mendation—the discharge location
and services that were determined by
the therapist as necessary to promote
patient safety and any recovery, as
based on the patient’s current level
of function and available resources
at discharge, coded as home without
physical therapy, home with outpa-
tient therapy, home with home thera-
pist, subacute rehabilitation/SNF, acute
rehabilitation, or extended care facility
without therapy.
• Match—when the actual discharge lo-
cation and services were the same as
the discharge recommendation in the
final therapist documentation.
• Mismatch—when the actual discharge
location or services were not the same
as the discharge recommendation in
the final therapist documentation.
䡩 Mismatch with services lacking—
the patient did not receive
follow-up services when a home
therapist was recommended.
䡩 Mismatch with different services
than recommended or extra servic-
es—the patient received home
physical therapy instead of recom-
mended outpatient therapy or the
patient received home therapy
when no follow-up therapy was rec-
ommended.
• Reason for mismatch, categorized as:
䡩 Patient refusal of placement—the
therapist recommended placement
or services, and the patient or his or
her legal representative declined,
䡩 Insurance issues—the therapist rec-
ommended placement or services,
and the patient did not receive them
due to lack of insurance or insur-
ance denial of services,
䡩 Medical complexity of the patient
precludes placement—the patient is
on a ventilator or receiving enteral/
parental feedings, for example, or
䡩 Other—any other reason.
Number 5 Physical Therapy f 697
 Acute Care Physical Therapists’ Discharge Recommendations
Table 1.
Patient Baseline Demographics
Variable
Patient age (y)
Length of admission (d)
Time from admission to physical therapist
evaluation (d)a
Time from physical therapist evaluation to
discharge (d)
a
Length of time to physical therapist evaluation was calculated from admission and did not take into
consideration when the consult was sent.
Table 2.
Mismatch Status by Discharge Location
Discharge Location
Home without physical therapy
Home with outpatient physical therapy
Home with home physical therapy
Subacute rehabilitation/skilled nursing
facility
Acute rehabilitation
Extended care facility, no physical therapy
Total
• Readmission—if the patient was admit-
ted to our acute care facility within 30
days of discharge, a time period con-
sistent with similar studies.11,20
Data Analysis
We used Microsoft Excel software
(Microsoft Office 2007)* for database
formation and SPSS software (ver-
sions 16.0 and 17.0)† for statistical
analyses. We used descriptive statis-
tics to summarize physical therapist
and patient characteristics. We cal-
culated the frequency of occurrence
of patient discharge locations, mis-
match, and readmission. Patients
who expired were included in demo-
graphic and descriptive data but ex-
cluded from statistical analyses of
mismatches or readmission. We used
a general linear modeling technique,
explained below, to determine
* Microsoft Corp, One Microsoft Way, Red-
mond, WA 98052-6399.
†
SPSS Inc, 233 S Wacker Dr, Chicago, IL
60606.
698 f Physical Therapy Volume 90
Downloaded from https://academic.oup.com/ptj/article-abstract/90/5/693/2737769
by guest
on 11 January 2018
14 days, and ⱖ15 days. Mismatch
status and discharge location were
X SD Range
categorized as previously defined.
63 17 0–83
We used this analytic approach
11 19 1–136
rather than the more common
4 4 0–37 method of linear regression for 2 rea-
sons. First, our response variable (re-
7 22 0–122 admission) is a dichotomous out-
come. Second, it allowed us to
control for the fact that each physi-
cal therapist made discharge recom-
mendations for multiple patients and
outcomes for a given therapist were
not independent.21,22 Preliminary
Match Mismatch Total models tested for correlation of out-
275 (83%) 58 (17%) 333 comes by physical therapy, but the
13 (93%) 1 (7%) 14 observed correlation was not sig-
nificant. The reported results speci-
150 (76%) 47 (24%) 197
fied an independent correlation
129 (88%) 18 (12%) 147
structure.
42 (100%) 0 (0%) 42
Results
10 (100%) 0 (0%) 10
Patient Demographics
619 (83%) 124 (17%) 743 Of the 780 patients we identified as
having received physical therapist
evaluations in the specified 4 weeks,
we successfully collected data from
which variables were associated the medical records of 762 patients.
with an increased risk of readmis- Eighteen patients were excluded be-
sion. An alpha level of .05 was used cause their discharge location or the
for all hypothesis testing. therapist recommendation could not
be determined. This situation oc-
We did logistic regression analysis curred when information was miss-
using generalized estimating equa- ing from the medical record or cler-
tions to control for correlation of the ical errors led to an inability to locate
outcomes by physical therapy and to the patient’s medical record. Of the
predict the probability that a patient 762 patients from whom we col-
would be readmitted. The predictor lected data, 743 were eventually dis-
variables we included in the model charged from acute care, and 19 ex-
were mismatch status, patient age, pired. Patients tended to be older
length of admission, and discharge adults who were distributed across
location. These are all of the vari- medical (48%), surgical (27%), neu-
ables we collected that could have rology (7%) and trauma/orthopedic
had an effect on readmission. Patient (18%) services. Although the ranges
age and length of admission were were broad, the patients had an av-
collapsed from continuous variables erage hospital admission of 11 days
into categories to allow for more and were evaluated by a physical
meaningful analysis. Age was catego- therapist around day 4 of their admis-
rized as ⱕ35 years, 36 to 55 years, 56 sion (Tab. 1). The discharge loca-
to 70 years, 71 to 84 years, and ⱖ85 tions of the patients from whom
years. Length of admission was cate- we collected data were as follows:
gorized as less than 2 days, 2 to 4 home without physical therapy
days, 5 to 7 days, 8 to 10 days, 11 to (44%), home with home therapy
Number 5 May 2010
 Acute Care Physical Therapists’ Discharge Recommendations

Table 3.
Reason for Mismatch by Discharge Location

Discharge Location

Home With Home With Subacute

Home Without Outpatient Home Physical Rehabilitation/Skilled
Reason for Mismatch Physical Therapy Physical Therapy Therapy Nursing Facility Total

Patient refusal of placement 8 (57%) 0 (0%) 4 (29%) 2 (14%) 14

Insurance issues 2 (100%) 0 (0%) 0 (0%) 0 (0%) 2

Missing home physical therapy with 40 (100%) 0 (0%) 0 (0%) 0 (0%) 40

recommendation

Received home physical therapy without 0 (0%) 0 (0%) 32 (100%) 0 (0%) 32

recommendation

Other 8 (22%) 1 (3%) 11 (31%) 16 (44%) 36

Total 58 (47%) 1 (1%) 47 (38%) 18 (15%) 124

(26%), subacute rehabilitation/SNF
(19%), acute rehabilitation (5.5%),
expired (2.5%), home with outpa-
tient therapy (2%), and extended
care facility without therapy (1%).
Mismatches
There was a mismatch between
physical therapist recommendation
and patient discharge location in 124
of 743 cases, or 17% of the time. The
breakdown by service groups was:
neurology/neurosurgery, 21%; medi-
cine, 19%; surgery, 16%; and trauma/
orthopedics, 7%. Mismatches are cat-
egorized by discharge location in
Table 2 and by reason for mismatch
in Table 3. The majority of mis-
matches occurred in patients who
were discharged home. The most
frequent reason for mismatch was
patients who did not receive home
therapy when recommended. The
second largest group of mismatches
were patients who received home
therapy services that were not rec-
ommended, a condition that reflects
unnecessary use of resources. Pa-
tient refusal of placement or services
was the third largest category, and
lack of insurance or insurance denial
of services caused very few
mismatches.
Although most mismatches occurred
in patients who were ultimately dis-
charged home, mismatches in the
“other” category of reasons for mis-
match did include patients who
were subsequently discharged to a
subacute rehabilitation facility or
SNF. These cases were scenarios
where no beds were available at the
recommended level of care in the
patient’s preferred geographical area
or where patients were denied ad-
mittance to an acute rehabilitation
facility despite the recommendation.
Readmission
As shown in Table 4, 139 patients
(approximately 18% of our sample)
were readmitted to our hospital
within 30 days of their discharge.
Our overall readmission rate is con-
sistent with that of other studies.20,23
In our logistic regression analysis to
predict the probability that a patient
would be readmitted, mismatch sta-
tus, discharge location, and length of
admission were significant predictor
variables. Patient age was not a sig-
nificant predictor variable.
Table 5 shows the results of
follow-up hypothesis testing. Hold-
ing all other variables constant, a pa-
tient was 2.9 times more likely to be
readmitted when the therapist dis-
charge recommendation was not im-
plemented and services were lacking
compared with patients with a match
(mismatch with services lacking ver-
sus match, odds ratio [OR]⫽2.89,
95% confidence interval [CI]⫽1.57–
5.30). Patients whose therapist dis-
charge recommendations were not
implemented and who received dif-
ferent services or extra services were
not significantly more likely to be
readmitted than patients with a

Table 4.
Patient Readmission by Mismatch Status

Not Odds Ratio

Variable Readmitted Readmitted Total (95% Confidence Interval)

Match 103 (17%) 516 (83%) 619 (100%) 1

Mismatch: services lacking 22 (35%) 41 (65%) 63 (100%) 2.89 (1.57–5.30)a

Mismatch: different services 14 (23%) 47 (77%) 61 (100%) 1.42 (0.79–2.56)

a
Significantly different risk of readmission compared with match at P⬍.01.

May 2010 Volume 90 Number 5 Physical Therapy f 699

Downloaded from https://academic.oup.com/ptj/article-abstract/90/5/693/2737769
by guest
on 11 January 2018
 Acute Care Physical Therapists’ Discharge Recommendations

Table 5. match (mismatch with different ser-

Odds of Readmission vices versus match, OR⫽1.42, 95%
95%
CI⫽0.79 –2.56).
Confidence
Predictor Variables Odds Ratio Interval Follow-up testing also revealed that
Mismatch patients discharged to an extended
Match Reference care facility were 6.9 times more
Mismatch: services lackinga 2.89 1.57–5.30
likely to be readmitted (OR⫽6.89,
95% CI⫽2.23–21.32) as compared to
Mismatch: different services 1.42 0.79–2.56
patients discharged home without
Discharge location
therapy. The results for patients dis-
Home without physical therapy Reference charged to an acute rehabilitation
Extended care facility, no physical therapya 6.89 2.23–21.32 setting approached significance in
Home with outpatient physical therapy 1.36 0.45–4.13 the direction of lower risk of read-
Home with home physical therapy 1.21 0.74–1.98
mission (OR⫽0.41, 95% CI⫽0.16 –
1.02) as compared to patients dis-
Subacute rehabilitation/skilled nursing facility 1.22 0.72–2.07
charged home without therapy. In
Acute rehabilitation 0.41 0.16–1.02
Figure 1 we show the different read-
Length of admission mission rates by discharge location.
0–1 d Reference

2–4 d 0.89 0.32–2.46 Physical Therapists

5–7 d 1.50 0.56–3.99
The 40 therapists included in the
sample had a mean of 110 months of
8–10 d 2.55 0.87–7.51
total experience as a practicing
11–14 d 0.91 0.26–3.15
physical therapist (range⫽3⫺354
ⱖ15d 0.85 0.33–2.20 months). As 23 of the physical ther-
a
Significant compared with reference at P⬍.05. apists had career experience beyond
the acute care setting, the range of
acute care experience was the same;
however, the mean was lower (mean
of 57.5 months of acute care
experience).

Discussion
Overall, patients were discharged in
accordance with the physical thera-
pist discharge recommendation 83%
of the time. When the discharge
recommendation was not imple-
mented and recommended follow-
up services were not received, pa-
tients were 2.9 times more likely to
be readmitted to our hospital within
30 days of discharge. Together, these
results indicate that therapists are able
to integrate multiple factors contrib-
Figure.
uting to the discharge needs of the
Rate of readmission by discharge location. Overall readmission rate was 18%, and
patients discharged to extended care facilities without physical therapy were signifi- patient to make accurate and appro-
cantly more likely to be readmitted to the hospital within 30 days. priate discharge recommendations.

An overall match rate of 83% be-

tween the therapist discharge rec-
ommendation and the patient’s ac-
tual discharge location and services

700 f Physical Therapy Volume 90 Number 5 May 2010

Downloaded from https://academic.oup.com/ptj/article-abstract/90/5/693/2737769
by guest
on 11 January 2018

indicates therapists are able to suc-
cessfully incorporate all of the vari-
ous factors involved in the discharge
planning process. This finding indi-
cates that there is value placed on
the therapist recommendation by
the final discharge plan decision
maker. It is possible, however, that
in some cases the discharge recom-
mendation happened to match the
patient’s actual discharge location
without actually influencing the de-
cision making of the nurse or prac-
tice management coordinator mak-
ing the final decision. It is difficult
for us to explain the patients who
did not receive home physical ther-
apy when recommended or the pa-
tients who received home therapy
services that were not recommend-
ed— by far the largest causes of a
mismatch. Either situation is a poor
outcome, as it leads to a patient lack-
ing in necessary services or unneces-
sary use of limited resources. These
cases ultimately reflect a lack of com-
munication between the physical
therapist and the practice manage-
ment coordinator, even though the
therapist recommendations were
clearly documented in the electronic
medical record.
In the case of patients not receiving
home physical therapy that was rec-
ommended, it is possible that the
therapist documentation was not
completed before the discharge plan
was in place and no verbal exchange
about the recommendation took
place, or that the practice manage-
ment coordinator did not value the
information. Alternatively, it is possi-
ble that the patient was not receiving
formal discharge planning and, de-
spite the therapist identifying the pa-
tient’s need for services, no one fol-
lowed up to set up home therapy
services. Interestingly, Mamon et al6
reported a similar finding that 43% of
patients over the age of 60 years who
were discharged home reported that
they had an unmet need for physical
therapy or rehabilitation services. Al-
May 2010
Downloaded from https://academic.oup.com/ptj/article-abstract/90/5/693/2737769
by guest
on 11 January 2018
Acute Care Physical Therapists’ Discharge Recommendations
though physical therapist recom-
mendations were not reported in
their study, the findings indicate that
there seem to be a number of pa-
tients being discharged with unmet
needs. Perhaps practice manage-
ment coordinators need to screen
patients for formal discharge plan-
ning needs at discharge or after dis-
charge, not just at admission. Pa-
tients lacking necessary follow-up
services are a problem that needs to
be addressed, as our findings show
that when physical therapist dis-
charge recommendations were not
implemented and recommended
follow-up services were not re-
ceived, patients were 2.9 times more
likely to be readmitted to our
hospital.
As the United States struggles to bal-
ance efficiency and quality of health
care, the ability of physical therapists
to provide accurate and appropriate
discharge recommendations becomes
even more important. Discharge plan-
ning is increasingly becoming part of
an integrated package of health care,
and even small reductions in readmis-
sion rates could free up capacity for
subsequent admissions in a health care
system where there is a shortage of
acute hospital beds.1 Decreases in re-
admission rates, appropriate allocation
of resources, and avoidance of unnec-
essary services can help contain esca-
lating health care costs.
Another aspect of containing health
care costs relates to the employment
of physical therapists in the acute
care setting. Since the initiation of
the Medicare prospective payment
system and its use of diagnosis-
related groups, payments to hospi-
tals have been determined based on
the patient’s diagnosis, regardless of
whether the patient receives ser-
vices such as physical therapy. Acute
care physical therapists have the
challenge of justifying their salary
cost to the hospital as outweighed by
the benefit to the patient and the
Volume 90
hospital. This challenge is difficult
for a number of reasons. Therapists
often are consulted to work with the
patients who are more medically and
functionally compromised—patients
who are more likely to have negative
outcomes than their less compro-
mised peers. In addition, therapists
often are advocating for additional
services for patients, such as dis-
charge to a rehabilitation facility, and
the patient’s length of stay often in-
creases as he or she waits for ad-
mission to another facility. These
findings demonstrate that therapists
benefit both the patient and the hos-
pital through their crucial role in the
discharge planning process. When
therapist discharge recommenda-
tions were implemented and recom-
mended follow-up services were re-
ceived, the patient and the hospital
had an increased likelihood of posi-
tive outcomes through a decreased
risk of readmission.
In addition to whether or not the
therapist recommendation was im-
plemented, risk of readmission also
was partially predicted by the pa-
tient’s actual discharge location. Pa-
tients discharged to an extended
care facility without physical therapy
were 6.9 times more likely to be re-
admitted, whereas patients discharged
to acute rehabilitation approached a
significantly lower risk of 0.4 times
as likely to be readmitted. This find-
ing probably reflects the nature of
illness and reason for admission of
these patients, and possibly reflects
the quality of follow-up care they re-
ceive. Patients usually are discharged
to an extended care facility without
a recommendation for continued
physical therapy because they are
very ill with a poor prognosis for
functional gains, whereas patients
are discharged to an acute rehabilita-
tion setting because it is believed
that they will tolerate and benefit
from at least 3 hours per day of in-
terdisciplinary rehabilitation. Acute
rehabilitation patients also continue
Number 5 Physical Therapy f 701
 Acute Care Physical Therapists’ Discharge Recommendations
to receive 24-hour nursing care and
the other benefits (and drawbacks)
of a hospital setting, whereas pa-
tients discharged home do not.
Patients discharged to subacute reha-
bilitation or an SNF also receive 24-
hour nursing care and daily rehabili-
tation, but, for a variety of reasons,
have not been admitted to acute re-
habilitation or discharged home. Fur-
ther speculation on the relationship
between discharge location and risk
for readmission is beyond the scope
and design of our study.
Of further interest, although we ac-
knowledge this information is spe-
cific to our facility, the frequency of
mismatch was not evenly distributed
across the different primary attend-
ing services that discharged the pa-
tients. Some services had a higher
rate of mismatch than others. The
rate was highest for neurology/neu-
rosurgery and lowest for trauma/or-
thopedics. One contributing factor
may be the nature of admissions; the
orthopedic surgeons perform a high
volume of planned surgeries com-
pared with the trauma/orthopedics
and neurology/neurosurgery ser-
vices, which have a lesser volume of
patients and larger proportion of un-
planned admissions. Planned admis-
sions allow patients adequate time to
confirm insurance benefits and con-
sider discharge needs ahead of time.
Different frequency of mismatch also
is likely related to the culture of each
service and differential value placed
on the physical therapist recommen-
dation, as well as the slightly differ-
ent processes by which communica-
tion is exchanged (eg, the presence
or absence of formal interdiscipli-
nary meetings). Within our 4 weeks
of representative data, evaluations
provided by each physical therapist
were distributed across the different
services, avoiding undue influence
of this phenomenon on our final re-
sults but still reflecting the service-
specific rates of mismatch.
702 f Physical Therapy Volume 90
Downloaded from https://academic.oup.com/ptj/article-abstract/90/5/693/2737769
by guest
on 11 January 2018
Limitations and Further
Questions
The major limitation of our study is
that it is unique to our facility and
may have limited generalizability to
other acute care settings. The large
size of our hospital leads to many
staff members in each discipline,
each of whom practices in an indi-
vidual manner within the commu-
nity of their discipline and within the
larger hospital community. Resident
physicians and physical therapists ro-
tate between service areas of the
hospital, interacting with different
members of the health care team and
providing care to different types of
patients within each area. As an aca-
demic medical center and level 1
trauma center, the facility tends to
care for patients who are more se-
verely ill and complex, which cer-
tainly influences discharge locations
and readmission rates.
In addition to the facility-specific as-
pects of our study, other limitations
were that we collected limited infor-
mation on the patients who received
physical therapist evaluations. We
did not address readmission of pa-
tients to hospitals other than our
own and we did not assess the rea-
son for readmission. We did not
collect information on reason for ad-
mission, severity of illness, comor-
bidities, or functional level of the pa-
tients, which is information that
would allow us to understand more
about patterns of recommendation
for discharge location or rates of re-
admission. In a cognizant effort to
respect patient privacy, we did not
collect information on patient sex,
race, or ethnicity, as we felt a discus-
sion of how these variables might
relate to discharge location and read-
mission rates was beyond the scope
of our report.
In regard to tracking readmission
only to our own hospital, our read-
mission rate reflects only readmis-
sion to our hospital and is likely
Number 5
lower than an overall readmission
rate, as there are almost certainly pa-
tients discharged from our facility
who were readmitted to facilities
closer to their home. Although our
readmission rate needs to be inter-
preted in context, the proportion of
mismatches should be accurate. Pa-
tients who were part of a mismatch
should have been equally likely to be
readmitted to our hospital compared
with an outside hospital. By not as-
sessing the reason for readmission,
we may have included patients who
were readmitted for purely medical,
and not functional, reasons. Overall,
readmission for any reason reflects a
failure of the discharge plan, which
may have been avoided with proper
supportive postdischarge care. A de-
cline in physical function is known
to contribute to emergency depart-
ment visits in older adults.24
Future research, with a larger sample
size, could investigate how clinical
experience influences the accuracy
of discharge recommendations of
acute care physical therapists. We
also think it would be interesting to
follow up with patients and gather
their perception of their recovery
and functional status in relation to
their discharge services and location.
We are particularly interested in the
patients who were functioning at a
level where both subacute rehabili-
tiation/SNF and home with home
physical therapy were viable op-
tions. In addition, we were not able
to address how frequency of acute
care physical therapist treatments in-
fluences discharge locations, which
may be of particular relevance in
these “borderline” situations.
Conclusions
Overall, our data strongly support
the role of physical therapists in dis-
charge planning in acute care. Phys-
ical therapists demonstrated the
ability to make accurate discharge
recommendations for patients with
complex clinical presentations who
May 2010

are acutely ill; these patients were
discharged in accordance with the
therapist discharge recommendation
83% of the time. More important, we
showed that the therapist discharge
recommendations were appropriate,
as patients were 2.9 times more
likely to be readmitted when the dis-
charge recommendations were not
implemented and recommended
follow-up services were lacking.
All authors provided concept/idea/research
design, writing, data collection, and consul-
tation (including review of manuscript be-
fore submission). Dr Smith and Ms Fields
provided data analysis. Dr Smith provided
project management. Ms Fields provided
participants. Dr Smith and Ms Fernandez
provided clerical support.
The authors thank the physical therapy staff at
the University of Michigan Hospital for their
participation and support, particularly Casan-
dra Redmon and Lauren Lobert for data col-
lection. They also thank Diane Jette, PT, DSc,
for her comments on the initial idea.
A poster presentation of this research was
given at the Combined Sections Meeting
of the American Physical Therapy Association;
February 17–20, 2010; San Diego, California.
This publication was made possible with
support from the Oregon Clinical and Trans-
lational Research Institute; grant UL1
RR024140 01 from the National Center for
Research Resources, a component of the
National Institutes of Health (NIH); and the
NIH Roadmap for Medical Research. Dr
Smith is supported by a National Institute of
Aging Institutional Training Grant to Jeri
Janowsky (principal investigator). During her
PhD studies, she was supported by grant
H424C010067 from the US Office of Special
Education and Rehabilitative Services to Dale
Ulrich (principal investigator).
May 2010
Downloaded from https://academic.oup.com/ptj/article-abstract/90/5/693/2737769
by guest
on 11 January 2018
Acute Care Physical Therapists’ Discharge Recommendations
This article was received May 22, 2009, and
was accepted January 3, 2010.
DOI: 10.2522/ptj.20090164
References
1 Shepperd S, Parkes J, McClaran JJ, Phillips
C. Discharge planning from hospital to
home. Cochrane Database Syst Rev.
2003;3:CD000313.
2 Jackson MF. Discharge planning: issues
and challenges for gerontological nursing:
a critique of the literature. J Adv Nurs.
1994;19:492–502.
3 Haddock KS. Characteristics of effective
discharge planning programs for the frail
elderly. J Gerontol Nurs. 1991;17:10 –14.
4 Hickey ML, Cook EF, Rossi LP, et al. Effect
of case managers with a general medical
patient population. J Eval Clin Pract.
2000;6:23–29.
5 Naylor M, Brooten D, Jones R, et al. Com-
prehensive discharge planning for the hos-
pitalized elderly: a randomized clinical tri-
al. Ann Intern Med. 1994;120:999 –1006.
6 Mamon J, Steinwachs DM, Fahey M, et al.
Impact of hospital discharge planning on
meeting patient needs after returning
home. Health Serv Res. 1992;27:155–175.
7 Bowles KH, Naylor MD, Foust JB. Patient
characteristics at hospital discharge and a
comparison of home care referral deci-
sions. J Am Geriatr Soc. 2002;50:
336 –342.
8 Wee JY, Wong H, Palepu A. Validation of
the Berg Balance Scale as a predictor of
length of stay and discharge destination in
stroke rehabilitation. Arch Phys Med Re-
habil. 2003;84:731–735.
9 Jette DU, Grover L, Keck CP. A qualitative
study of clinical decision making in recom-
mending discharge placement from the
acute care setting. Phys Ther. 2003;
83:224 –236.
10 Potthoff S, Kane RL, Franco SJ. Improving
hospital discharge planning for elderly pa-
tients. Health Care Financ Rev. 1997;19:
47–72.
11 Haddock KS. Collaborative discharge plan-
ning: nursing and social services. Clin
Nurse Spec. 1994;8:248 –252.
12 Gill TM, Williams CS, Tinetti ME. The com-
bined effects of baseline vulnerability and
acute hospital events on the development
of functional dependence among
community-living older persons. J Gerontol
A Biol Sci Med Sci. 1999;54:M377–M383.
Volume 90
13 Boyd C, Landefeld CS, Counsell S, et al.
Recovery of activities of daily living in
older adults after hospitalization for acute
medical illness. J Am Geriatr Soc. 2008;
56:2171–2179.
14 Covinsky KE, Palmer RM, Fortinsky RH,
et al. Loss of independence in activities of
daily living in older adults hospitalized
with medical illnesses: increased vulnera-
bility with age. J Am Geriatr Soc. 2003;51:
451– 458.
15 Coleman EA, Min SJ, Chomiak A, Kramer
AM. Posthospital care transitions: pat-
terns, complications, and risk identifica-
tion. Health Serv Res. 2004;39:
1449 –1465.
16 Ensberg MD, Paletta MJ, Galecki AT, et al.
Identifying elderly patients for early dis-
charge after hospitalization for hip frac-
ture. J Gerontol. 1993;48:M187–M195.
17 Jette DU, Brown R, Collette N, et al. Phys-
ical therapists’ management of patients in
the acute care setting: an observational
study. Phys Ther. 2009;89:1158 –1181.
18 Curtis KA, Martin T. Perceptions of acute
care physical therapy practice: issues for
physical therapist preparation. Phys Ther.
1993;73:581–594; discussion 594 –598.
19 Guide to Physical Therapist Practice. 2nd
ed. Phys Ther. 2001;81:9 –746.
20 Einstadter D, Cebul RD, Franta PR. Effect
of a nurse case manager on postdischarge
follow-up. J Gen Intern Med. 1996;11:
684 – 688.
21 Pagano M, Gauvreau K. Principles of Bio-
statistics. Florence, KY: Wadsworth Pub-
lishing Co; 1993.
22 Resnik L, Liu D, Hart DL, Mor V. Bench-
marking physical therapy clinic perfor-
mance: Statistical methods to enhance in-
ternal validity when using observational
data. Phys Ther. 2008;88:1078 –1087.
23 Bowles KH, Ratcliffe SJ, Holmes JH, et al.
Post-acute referral decisions made by mul-
tidisciplinary experts compared to hospi-
tal clinicians and the patients’ 12-week
outcomes. Med Care. 2008;46:158 –166.
24 Wilber ST, Blanda M, Gerson LW. Does
functional decline prompt emergency de-
partment visits and admission in older
patients? Acad Emerg Med. 2006;13:
680 – 682.
Number 5 Physical Therapy f 703