Harmony Healthcare Blog

SNF Discharge Planning for High Level Patients

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Wed, Jun 22, 2011
Kris Mastrangelo, OTR/L, LNHA, MBA
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Harmony consultants often work with the therapy professionals in the SNF to grow the discharge planning treatment programs.  Harmony provides a general outline of the high level areas that therapists should assess prior to discharging patients to home or the community.


  •  Physical mobility
  • High level basic ADL's
  •  Instrumental ADL's
  • Community re-entry
  • Cognitive skills
  •  Communication


Several key areas for assessment include, but are not limited to:




Physical Mobility


  • Ability to incorporate restrictive precautions (hip, back, sternal, cardiac) into daily routine, functional mobility and tasks.
  • Advanced transfers; low surface, soft surface, no armrests, car.
  • Multi-surface gait; grass (soft mat simulates grass), gravel, brick; inside and outside 
  • Opening doors
  • Fall recovery 


Activities of Daily Living


  • Dressing; includes management of braces, TED hose, obtaining and returning clothing to closet or dresser
  • Tub and shower transfers
  •  Bathroom safety including access of cupboards
  • Empty and clean bedside commode


Instrumental ADL's


  • Self-medication (including oxygen, opening containers, timing)
  • Sweeping/mopping/ vacuuming; all require good trunk control and balance
  • Spill management
  • Pet care; food, water, litter box
  • Laundry; washer, dryer, ironing
  • Kitchen skills and safety:
    •   Meal planning and preparation
    • Retrieve objects from high/low cupboards, bottom of fridge.
    •  Safe use of appliances; coffee maker, toaster, microwave, dishwasher.
    • Putting away groceries in cupboard/fridge
    •  All patients discharging to home or ALF should be able to obtain, prepare and transport drinks and light snacks even if they are not primarily responsible for meal preparation


Community Re-entry


  • Ability to cross street; safety with cross walk, velocity
  • Retrieve mail
  • Grocery shopping, including transport of bags
  • Banking and money management
  •  Restaurant; access, choice of meals within restrictions
  • Car transfers and access public transportation  


Cognitive Skills


  • Managing finances; budgeting, banking, bill paying
  • Response to emergencies
  • Using telephone or alert system
  • Reading; following instructions
  • Telling time; important for appointments and medication management


The Medicare team will provided the patient and family with goals related to the above areas to achieve prior to discharge. This discussion should be initiated upon patient admission to the facility.


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