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Clarice Grote, MS, OTR/L

How to Make a Successful Occupational Therapy Discharge Plan

Have you ever felt like no one listens to your clinical judgment when it comes to your occupational therapy discharge plan?

I used to feel like this until I started talking to case managers and learned the secret to a successful discharge plan… Insurance!

I love discharge planning, so I put together a podcast, this article, AND a free OT discharge guide to help you confidently make effective discharge plans! A successful discharge plan also comes from understanding how each setting interacts with the other to create the healthcare continuum of care.

Patients rely on us to help them navigate this crazy healthcare system of ours so it is our job to understand what each setting is, what makes it unique, why a patient might need one setting over another, and what discharge setting may be covered by their insurance. Of course, we can’t know everything, but having a basic understanding is really important.

In this article, we’ll discuss:

  • When to start discharge planning
  • Using discharge plans to set goals
  • Discharge planning in continuum of care
  • Appropriate discharge settings
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Podcast: Ep 8. How to Make a Successful Occupational Therapy Discharge Plan

Check out this episode for information on how Medicare and health insurance impacts what discharge plans may be available to a patient.

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Free Continuum of Care Download 👇

When to Start Your Occupational Therapy Discharge Plan

Discharge planning should start from the very first visit! It’s okay to not know exactly where the patient will be going yet, but starting the conversation helps both you and the patient prepare for when therapy might end.

Patients and families often have a lot of anxiety around services ending especially if they experienced a medical event that significantly changed their function and life. The sooner we can start that conversation, the better they will be prepared and the better they will feel about discharge.

It’s empowering to the patient to know they aren’t dependent on us for recovery and also helps reduce anxiety around when services will inevitably end.

Using Discharge Plans to Set OT Goals

Discussing discharge at the evaluation helps us know what goals are important to our patient and also helps us discuss reasonable expectations for the plan of care. Understanding the discharge situation helps us know where a patient will be staying (because they can’t stay in the hospital or SNF forever…), who will be with them, their home set up, and what resources they may need.

All of these discharge factors are important influences we can incorporate into our goals. We can also use this info to alert a social worker or case manager about the patient’s long-term needs so they can begin working on helping the patient access those resources upon discharge. For example, if someone needs bathing assistance long term in home health, then we should work on setting that up from the start of care, not just on the last day of discharge.

Thinking long term like this helps set the patient up for success, shows the value of our insights as an occupational therapy practitioner, and also helps reduce healthcare expenditures and preventatives events which are important to our system and our agencies.

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Occupational Therapy Discharge Plans as Part of the Continuum of Care

The Continuum of Care is the patient’s journey in the healthcare system. Generally, patients start in acute care and work their way to outpatient. The Continuum of Care is important to know because what you do with your patient in one setting will impact their therapy experience later down the line because we do not work in silos. The Continuum of Care is interconnected and their are specific admission requirements in each setting.

Here are some important things to note about the Continuum of Care:

  • Acute care – patients may or may not have therapy during their hospital stay
  • Long-term care hospital – patients stay here for an average of 25 days or longer
  • Inpatient rehab facilities – patients require 3 hours of therapy a day
  • Skilled nursing facilities – patients require 1 skilled service a day, may or may not be therapy
  • Home health – patients must be homebound and need another qualifying service (beside OT) at start of care
  • Outpatient – patients require intermittent therapy and are not bound to the home

Free Detailed Continuum of Care Download 👇

Occupational Therapy Discharge Plans in Acute Care

Acute care is where discharge planning is queen! Therapy is often consulted to assist with discharge planning due to our expertise in function, mobility, and assessing a patient’s ability to discharge safely to home. (Hint – hospitals really want to avoid readmissions and OT is proven to reduce hospital readmissions).

Discharge planning can often be complex in acute care because practitioners have to consider the patient’s condition, anticipate how they might improve, the home environment, help at home, what health insurance will approve (which is different from what is covered), where the patient wants to go, and dozens of other factors.

Another note, post-acute care facilities are not required to accept patients. So, some facilities may decline to take patients with certain conditions or home situations if they feel they are unable to accommodate their needs. Any patients with a history of a recent inpatient mental health stay, violence, incarceration, or a sexual assault conviction will often have a more difficult time finding post-acute care centers that will accept them as an admit. This is also why we have to be very careful when we label patients at violent or aggressive in our documentation because this can seriously impact their ability to discharge.

There are two options for admission status when a patient is in acute care: inpatient or outpatient. While both patients may be staying in the hospital, this status determines payment, the type of care provided, and what services they are eligible for at discharge.

Medicare patients that are admitted under observation status are unable to discharge to a skilled nursing facility because they do not meet the 3 midnight requirement. So, if your patient is not an inpatient and you recommend SNF, you’ll be setting them up for an unrealistic discharge plan because Medicare won’t pay for it, and your patient certainly won’t want to pay for it out of pocket. See… isn’t insurance fun!? 🤪

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Getting help from the team: Case Management and Social Work

Communication with case managers and social work is essential in acute care for successful discharge plans. Talking with them about your observations and the patient’s needs helps inform them on our role and why OT is valuable (hint – helps you get more referrals for OT) and is also an opportunity to learn about what discharge plans might be the most realistic based on that patient’s factors.

Some insurances – especially Medicare advantage – can be really finicky about when they will or will not approve inpatient rehab facilities (IRF). So if you have an insurance that almost never approves coverage for IRF, then you’ll know you need to start talking to the patient about SNF or home just in case.

This is also a great time to communicate information they need. You’re doing them a favor by saving them time and again you’re showing them the value of your services. Just like nurses control the keys to the castle in the hospital, case managers and the social work team hold the keys to the patient leaving the hospital and what services and information is passed onto the next stage. Don’t hesitate to reach out to the team, ask them questions, and ask how you can make their lives easier. We’re all part of an interdisciplinary team and the more we work together the better outcomes for the patient.

Can I just recommend any discharge setting?

Ahh… if only it were so easy! My number one piece of advice is to NEVER make promises when it comes to discharge planning.

Unfortunately, what discharge settings are an option for patients greatly depends on their health insurance. Medicare has specific guidelines on when a patient can be admitted to certain settings like inpatient rehab facilities and skilled nursing facilities. This is often referred to as admission criteria. Fortunately, I put all this info into a quick reference guide – the Adult Rehab Guide™.

I also talk a lot about it in the podcast above and the “How Insurance Impacts Your Plan of Care” episode/article. If you’re a visual learner like me (I see you 😉), I’ll spell it out here in our free handout. 👇

Make discharge plans with confidence!

Is it all starting to come together just how much insurance influences your plan of care? Understanding how insurance and payment models influence our plans can make you a better OT discharge planner by

  • Increasing your clinical judgement and competency
  • Decreasing frustration for the care team and patient
  • Helping patients access the care they need and can afford

If this topic has your mind turning, then you might as well add the free OT Podcast Playlist to your resource bank! It’s a free resource that includes this podcast and others to help you learn more about insurance and Medicare the easy way! Fill out the form below👇 to get the free resource!

Have additional questions about discharge planning? Send me an email or reach out on Instagram!


Special thanks to Lindsay Bright, OTD/S for her work on this article!

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hi there,

I’m  Clarice

Occupational therapist & medicare specialist helping practitioners understand policy, engage in advocacy, and own their value!

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