A Discharge Checklist to Combat Patient Readmission: A Case

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A Discharge Checklist to Combat Patient Readmission: A Case A Discharge Checklist to Combat Patient Readmission: A Case

Study in a Skilled Nursing Facility Study in a Skilled Nursing Facility

Shaylin O’Connell

George Washington University

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Running Head: A DISCHARGE CHECKLIST TO COMBAT READMISSION

A Discharge Checklist to Combat Patient Readmission: A Case Study in a Skilled Nursing

Facility

Shaylin O’Connell, MS, OTR/L

The George Washington University

Author Note

Shaylin O’Connell, MS, OTR/L, is a student at The George Washington University’s School of

Medicine and Health Science completing Doctoral Capstone OT 8276 under advisement of

GWU faculty Jeremy Furniss, OTD, MS, OTR/L, BCG and Dr. Leslie Davidson, Ph.D., OT/L,

FAOTA. Correspondence concerning this article should be directed towards Shaylin O’Connell,

[email protected].

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Abstract

A Discharge Checklist to Combat Patient Readmission: A Case Study in a Skilled Nursing

Facility focuses on the creation of a discharge checklist, as an intervention, to increase the

competency for occupational therapists working in skilled nursing facilities discharging clients

back to their home environment. A SNF (Skilled Nursing Facility) provides post-acute

healthcare services and rehabilitation for patients following a hospitalization prior to discharging

home (Burke et al., 2017). This case study for clinical improvement uses the DMAIC (define,

measure, analyze, improve, control) quality model and a multiple case study research design for

evaluation. The goal of the quality improvement process is to increase the competency of

occupational therapists discharging clients to prevent reoccurring hospitalizations due to

missed information during the discharge process. Based on the overall findings through a pretest

and posttest design, an outcomes survey using a Likert scale, and a qualitative survey, the three

participants self reported higher clinical competency following use of the intervention. This case

study approach found anecdotal evidence that the discharge checklist benefitted three

occupational therapists by providing a streamlined approach to identify and address potential

barriers for clients returning to their home setting.

This project provides the development of a comprehensive discharge checklist for

implementation by occupational therapists working in a SNF. The checklist was initially

informed by a literature review and the author’s clinical experience. Qualitative feedback from

three additional occupational therapists supported the revisions to the discharge checklist. The

improved version of discharge checklist is available for occupational therapist to use in the future

following this case study. The George Washington University IRB review board approved this

research project.

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A Discharge Checklist to Combat Patient Readmission: A Case Study in a Skilled Nursing

Facility

Literature Review

Research currently indicates there is a significant financial loss and increased patient

complications occurring from unnecessary hospital readmissions (Mileski et al, 2017). The

Department of Health and Human Services Office of the Inspector General found that 31% of

patients’ stays did not meet discharge planning requirements (Levinson & General, 2013). One

example included not having a post discharge plan of care which specifies the instructions to

meet the patient’s needs at the time of discharge (Levinson & General, 2013). This resulted in

Medicare paying approximately $5.1 billion for patients staying at skilled nursing facilities who

did not receive the required discharge planning resulting in reduced quality of care (Levinson &

General, 2013). With this large financial burden, healthcare systems are looking for solutions to

eliminate high, preventable costs by updating their current systems and processes to avoid this

problem to avoid hospital readmissions. Some avoidable readmissions are related to poor

communication throughout the transition of care and lack of patient and family member

engagement and understanding of the overall plan of care (Berkowitz et al., 2013).

Due to the high costs associated with patients being readmitted shortly after discharge,

there is an opportunity to identify and evaluate strategies that will reduce readmissions. Tole and

colleagues, (2016) discuss how patients’ preparedness for discharge and hospital readmissions in

the acute hospital setting are improved through discharge interventions provided by professional

staff. Additionally, Rogers and colleagues, (2017) discuss how occupational therapists in

hospitals are associated with lower readmission for patients with heart failure, pneumonia, and

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acute myocardial infarction. The study further discusses how discharge planning in occupational

therapy interventions may lead to lower readmission rates by addressing the critical question

about the patient’s safety to return to their home environment. The occupational therapist who

can further provide skilled intervention services to increase the patient’s ability to be discharged

to prevent further rehospitalization addresses the patient’s safety through discharge planning

(Rogers et al., 2017).

Occupational therapy and a systematic discharge planning mechanism may reduce

hospital readmission and improve patient safety for individuals discharging from a skilled

nursing facility. A more structured and systematic discharge process may improve the transition

between the healthcare facility and home by ensuring a patient has the proper support and

training at the time of discharge to address the completion of activities of daily living.

Furthermore, a competency-based education approach with the patient ensures that the

instructions and education from the discharge checklist are understood by the patient as the

patient demonstrates what they have learned and their mastery of knowledge (Krause et al.,

2015). Without addressing and researching potential solutions to prevent readmissions, we will

continue to see increased money spent by Medicare, Medicaid, insurance companies, and clients

who were prepared or safe to be discharged home.

According to the “Occupational Therapy Practice Framework (OTPF): Domain and

Process”, it is within the domain of occupational therapy practice to create an intervention plan

inclusive of discharge planning (AOTA, 2014). Occupational therapists need to consider the

patient’s discharge plans to determine their needs within occupational therapy’s scope of

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practice. This may increase the outcomes stated in the OTPF to prevent and reduce the patient’s

risk factors, barriers and limitations, which could result in a rehospitalization (AOTA, 2014).

Problem Statement

With inconsistencies during the discharge planning process, both occupational therapists

and patients are uncertain when it comes to the discharge process. Occupational therapists need

to ensure that patients returning home are able to complete activities of daily living (ADLs) and

instrumental activities of daily living (IADLs) safely and independently or if they need

assistance for activities, a caregiver demonstrates ability to provide the level of assistance

needed. Discharge specific interventions for patients transitioning from the hospital to home

have shown positive outcomes such as increased preparedness for discharge and decreased

hospital readmission within 30 days (Tole et al., 2016). Based on these findings, there is an

opportunity to improve the discharge process for patients transitioning from skilled nursing

facilities to home by having occupational therapist utilize a systematic discharge checklist to

facilitate the patient’s preparedness and ultimately reduce hospital readmissions.

Project Statement and Study Objectives

The objective of this doctoral capstone is to create a discharge checklist (Appendix A) for

occupational therapists working in skilled nursing facilities. This discharge checklist will be

initially created by conduction a literature review and using the author’s clinical experience. The

feasibility of this initiation version will be evaluated by three occupational therapist who will

utilize this tool with two or more patients during their initial evaluation. By using this checklist

at the start of care, it ensures that the occupational therapist will focus the plan of care around

goals and treatment that are needed to facilitate a successful discharge. After the initial

implementation and feasibility testing, the discharge checklist will be refined and improved.

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The third objective is to understand if the discharge checklist improves the occupational

therapist’s competency to systematically and efficiently review all aspects of the discharge

checklist. When the occupational therapist test the initial discharge checklist, a pre-post survey

will be conducted to understand if the checklist improved their perceived competency.

The intended result of this capstone is to increase the perceived competency of

occupational therapists discharging clients throughout the discharge process and improve the

quality of care provided to the patients using a discharge checklist. This capstone’s goal is to

benefit both occupational therapist and patients by provided streamlined discharge checklist to

address potential barriers for safe and successful completion of activities of daily living for

patients discharging home.

Research Goals

Currently, there is no standardized set of questions or consistent process for occupational

therapists to discharge a patient from a skilled nursing facility. Each evaluating occupational

therapist asks different questions in the initial evaluation without a consistent template resulting

in missing crucial information when discussing discharge plans. This presents the need for a

discharge checklist to support occupational therapists to discharge patients systematically and

efficiently. The goal is to implement a discharge checklist to determine if it is feasible to provide

a consistent planning tool between the evaluating occupational therapists to eliminate any gaps in

care prior to a patient discharging home based on using the discharge checklist. These needs will

be addressed by developing and introducing a streamlined occupational therapy discharge

checklist to address potential barriers and challenges for clients returning home (Toles et al.,

2016).

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Study Site & Participants

Inclusion & Eligibility

The site for this study was a 250+ bed, skilled nursing facility located in an urban area.

Participants were eligible to participate in this study if they were a licensed occupational

therapist, English speaking, and currently working at the study site.

Sampling Strategy

Recruitment of the potential subjects occurred through a verbal announcement from the

student researcher in order to recruit a convenience sample of occupational therapists from one

skilled nursing facility. The verbal announcement provided the research study topic, purpose,

problem statement and research questions.

Informed Consent

Occupational therapists contact the student researcher if they were interested in

participated in the study. After the potential participants initiated contact, the student researcher,

provided a verbal informed consent process and answered any questions. Once the participants

were consented, we protected their privacy by using an anonymous identifier through the data

collection process.

Conceptual Framework

The DMAIC framework (define, measure, analyze, improve, control) creates a roadmap

to support a quality improvement project at a skilled nursing facility. This framework provides a

strategy to improve the discharge process (Pyzdek, 2003). Each step of the roadmap highlights

the specifics of the DMAIC framework in order improve discharge planning by defining the

problem, measuring and analyzing the current outcomes, providing an improvement and

providing a control to determine the feasibility.

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Define

The DMAIC model first defines that many patients who are readmitted to hospitals

following a previous hospitalization results in unnecessary and increased healthcare spending

(Vasilevskis et al, 2017). It is estimated that 23% of Medicare patients who are discharged from

a skilled nursing facility will be readmitted within 30 days (Mor et al, 2010).

Measure & Analyze

Readmissions are publicly reported in post-acute care on the nursing home compare

website (“Medicare Nursing Home Profile”). The most recent publicly reported score for this

facility is based on the Quality of Resident Care Measure from CMS (Centers for Medicare &

Medicaid Services) current collection from July 1, 2017 through June 30, 2018 (“Medicare

Nursing Home Profile”). For short-term residents in this specific facility, CMS calculated and

provided the data regarding the percentage of short-stay residents who were re-hospitalized after

a nursing home admission. 22.1% of short-term residents were re-hospitalized after admission,

which is slightly higher than the District of Columbia’s average of 21.2%. However, compared

to the national average of 22.3%, this facility has a lower percentage of short-stay residents who

were re-hospitalized (“Medicare Nursing Home Profile”). The facility’s readmission score

indicates this is an area to address. The discharge checklist may facilitate higher quality of care

in areas that are related to lower readmission rates.

Improve

One potential solution to this problem is further evaluation of the discharge process in

skilled nursing facilities to develop a discharge checklist for occupational therapists to use. The

discharge checklist aims to facilitate successful transitions upon discharge from the skilled

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nursing facility back into the community. This checklist serves as a reminder and tool for

occupational therapists to review key elements of a client’s occupational performance prior to

discharge. This project explores the feasibility of implementing a discharge checklist in this

setting. A pretest and posttest survey has been derived and expanded from previous research in

order to assess clinician’s self-rated competency prior to utilizing the discharge checklist and

following the use of the tool (Langford et al., 2019; Lescinskas et al., 2018). Additionally, a

qualitative survey was utilized for feedback in order to create a second iteration of this tool. The

changes in the overall measurements for the readmission rate are beyond the scope of this

project. If the occupational therapists find the discharge checklist useful through this case study,

the facility may implement this process as specified in the DMAIC. A feasible checklist may be

a potential quality improvement tool that could be implemented in other facilities in the future.

Assessing Feasibility and Control

To support quality improvement and analysis, each participant provided feedback

through debriefing to provide feedback for a second version of the discharge checklist to utilize

in potential future research. The improvements were informed by the prioritization of trends

from the debrief, the themes identified and the specific recommendations of the therapists. The

data collection highlighted the occupational therapist's updated clinical competencies around the

discharge planning process. This information was collected through a pretest and posttest survey

to gain insight on the potential improved competency and confidence of the occupational

therapists participating in this capstone.

Methods and Data Collection

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Discharge Checklist Creation

A discharge checklist was created and expanded upon based on multiple sources

(American Occupational Therapy Association, 2014; Folstein et al., 1975; Halasyamani et al.,

2006; Levinson & General, 2013; Mahoney & Barthel, 1965). This discharge checklist uses

information from the Modified Mini Mental (Folstein et al., 1975), Barthel Index (Mahoney &

Barthel, 1965) and Occupational Therapy Practice Framework (American Occupational Therapy

Association, 2014) to focus on occupations, client factors, performance skills and factors, and

context and environment and the author’s clinical experience. These sources were used to best

create an overarching picture of the client’s previous level of function, current level of function,

and the gaps that need to be addressed to create a safe discharge plan home to reduce the

readmission rate. The discharge checklist evaluates the client’s discharge environment, the

durable medical equipment they currently have and the durable medical equipment they will

need based on the new onset of deficits. The discharge checklist also looks at the client’s current

ADL and IADL completion, including their community mobility for personal and medical

related appointment (Appendix A).

Pretest and Posttest Evaluation

The pretest survey (Appendix B) and posttest survey (Appendix C) were derived and

expanded from previous research to assess the occupational therapists’ competency prior to

utilizing the discharge checklist and following the use of the tool to define and analyze potential

improvements (Langford et al., 2019; Lescinskas et al., 2018). A Likert Scale was used to

determine the outcomes using a 1-5 scale (1: strongly agree-5 strongly disagree). The pretest and

posttest data collection was collected through paper surveys and were identified by a numerical

labeling system to protect the participants’ privacy. The answer key to the surveys was stored

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in a locked filing cabinet and only one person had access to the key. The answer key never

remained in the facility without the key holder’s presence.

The occupational therapists’ competency for discharge planning was first collected

immediately following the introduction of the project (Appendix B). Once those findings were

collected, the student researcher explained in detail all parts of the discharge checklist including

the instructions for use and the goal to use it with at least two clients during the initial evaluation.

The student researcher answered any questions and provided an open line for communication

throughout the project for any questions from the participants. Following the implementation of

the discharge checklist with a minimum of two separate clients, participants completed the

posttest survey, a quantitative outcomes survey and a qualitative survey in order to provide more

specific feedback and critiques of the discharge checklist. The data was collected to provide

detailed feedback for the creation of the second version based on the use of the first iteration in

practice. The individual results are summarized below through de-identified data.

Training in the Discharge Checklist

Three occupational therapists were trained on the use of the discharge checklist by the

student researcher. The training included a review of the checklist and a question and answer

session with any concerns regarding implementing this checklist in the therapist’s practice. The

goal was for the therapist to use the checklist with at least two clients and then provide initial

written feedback to the student researcher. Following use of the discharge checklist, the

participants completed the posttest competency survey (Appendix C), an additional quantitative

outcomes survey to look at the impact and comfort with discharge planning (Appendix D) and a

qualitative survey for overall feedback of the discharge checklist (Appendix E).

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Outcome Evaluation

There are a number of immediate and long-term outcomes highlighted in a logic model

(Appendix F) that may occur based on this capstone to create a streamlined discharge checklist

for a skilled nursing facility. The focus of the data collection for the outcomes is to analyze the

change in competency during the discharge process. The outcome for the goal is to implement a

discharge checklist to determine if it is feasible to provide a consistent planning tool, which will

be measured, based on the feedback from the participants of the project. This will be evaluated

through the data collection from the occupational therapists based on their overall experience

with the capstone project. Specifically, the occupational therapists will be rating their perceived

clinical competency with discharge planning.

The program will be found successful if the occupational therapists have shown an

increased competency discharging patients using the discharge checklist prior to patients

returning home. If the checklist is found to increase the competency of occupational therapists in

this case study, the project can move forward in future research to examine more comprehensive

outcomes, including client satisfaction. The long-term outcomes include lower hospitalization

readmissions, increased quality of life for clients, and decreased spending for CMS. These long-

term outcomes will not be measured as part of this capstone based on the time frame for

completion, however, based on the findings, future research will be recommended which will

require additional time and financial resources.

The overall goal is to update and change the practice of the discharge planning process

based on evidence-based practices. If the capstone delivers on the intended results that support

the idea that a discharge checklist will increase occupational therapists’ competency during the

discharge process, this may further encourage the idea of utilizing the created discharge checklist

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at this one SNF. This capstone will provide a streamlined discharge checklist to give a physical

planning tool for occupational therapists in order to support increased competency during the

discharge planning process.

Analysis

For the quantitative data collection, a pretest and posttest design looked to analyze the

data for the feasibility of using the discharge checklist in clinical practice and the potential

improvements to the occupational therapists’ clinical competencies. The single group of

participants included three occupational therapists who agreed to participate in the pretest survey

prior to the participation of the quality improvement phase and then the posttest survey to

measure the results at the conclusion of the study. The dependent variable is the occupational

therapist’s perceived clinical competency with discharge planning using the discharge checklist.

This was measured twice, one before use of the discharged checklist tool and once following the

use of the checklist. All the participants were given the same surveys with instructions how to

participate in the capstone. Descriptive statistics will be provided for each individual therapist.

The pretest and posttest quantitative data collect was further analyzed in Microsoft Excel

to look at the differences following the intervention. Additionally, in the posttest section, there

was an additional outcomes sections created using a Likert scale to measure the overall findings

of participation from the occupational therapists to rate their current knowledge and comfort with

discharge planning. The qualitative data collection occurred through open-ended survey

questions following the training. These responses were analyzed through categorization to

determine the themes presented based on the feedback from the questions to assist with final

edits of creating the second version of the discharge checklist.

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Findings and Results

Based on the quantitative findings each participant improved their overall competency

with discharge planning at varying levels based on the specific questions collected prior to the

intervention and following the intervention for comparison. The interesting findings of the case

study approach are the data of each individual participant from their experience to highlight

themes that were presented. See Table 1 for scores from all participants.

Participant One: For participant one, it was found that all of the scores following the quantitative

survey improved (Appendix G) for questions 1-5 demonstrating an increase in agreeing with the

items related to comfort discharging a client to the community and confidence with discharge

recommendations and using the discharge checklist. However, question “6.) I collect the same

information each time I discuss discharge planning in an initial evaluation with a patient”,

participant one found to have the same score at the pretest. Overall participant one decreased

their overall score of 1.83, which demonstrates improvement following the use of the discharge

checklist. The outcomes survey (Appendix D) collected feedback from the participant following

the use of the discharge checklist. Based on the 1-5 scale (1: strongly agree- 5: strongly

disagree), participant one’s average score was 1.33 for the provided questions.

Participant Two: Participant two had scores that lowered following the quantitative

survey (Appendix H) for questions 1-6 demonstrating increased agreement with all the items in

Table 1. Overall participant one decreased their overall score of 3, which demonstrates

improvement following the use of the discharge checklist. The outcomes survey (Appendix D)

collected feedback from the participant following the use of the discharge checklist. Based on

the 1-5 scale (1: strongly agree- 5: strongly disagree), participant one’s average score was 1.66

for the provided questions.

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Participant Three: Participant three’s scores following the quantitative survey lowered

(Appendix I) for question 2 demonstrating increased agreement with item two, “I am confident

using a discharge checklist tool.” This participant did not see any changes in score from the

pretest to posttest for the remaining questions. Overall participant three decreased their overall

score by 0.5, which demonstrates improvement following use of the discharge checklist. The

outcomes survey (Appendix D) collected feedback from the participant following the use of the

discharge checklist. Based on the 1-5 scale (1: strongly agree- 5: strongly disagree), participant

one’s average score was 2.83 for the provided questions.

Table 1 (Quantitative pretest and posttest findings of the participants using the discharge

checklist):

Items

Participant 1

Participant 2

Participant 3

Pre

Post

Pre

Post

Pre

Post

1.) I feel comfortable with

recommending patients to be

discharged back into the community

2.) I am confident using a discharge

checklist tool

3.) I am confident in identifying factors

pertinent from a discharge checklist to

provide an effective discharge plan

4.) I am competent collecting the

correct information in the beginning of

discharge planning

5.) I have a thorough process when

collecting discharge planning

information

6.) I collect the same information each

time I discuss discharge planning in an

initial evaluation with a patien

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Another view of the findings compared each participant side by side based on their

overall pretest and posttest score difference by the questions to see if any of the questions stood

out of having the most difference following the intervention (Appendix J). It was found that

question 2, I am confident using a discharge checklist tool, had the most overall change for all

the participants which they all ended up responding saying they either “agree or strongly agree”

to that question.

From the outcomes survey (see Table 2), a Likert scale (1-5) (Appendix D) was used at

the end of the project, all participants either “agreed” (2) or “strongly agreed” (1) for all parts of

question one (a-d), that the discharge checklist “helped me improve my knowledge of how to a.)

Identify risk factors prior to discharge, b.) Articulate goals of discharge planning, c.) Safely

initiate discharge planning, d.) Safely modify discharge planning through a patient’s stay”. The

findings for question two were neutral at a 3.33 as the participants stated that as a result of

completing the discharge checklist, I am now more likely to use the discharge checklist in care of

patients. Lastly, for all parts of question three (a-g), participants stated that after completing the

discharge checklist training they “agreed” (2) to “strongly agreed” (1) that a.) I am confident in

my ability to manage discharge planning, b.) I am capable of managing a discharge checklist

throughout discharge planning, c.) I am able to provide thorough recommendations for patient to

be discharged home, d.) I am able to meet the challenges of discharge planning for skilled

nursing facility patients, e.) My perception of my discharge planning knowledge has improved,

f.) The discharge checklist has a positive impact on my use of discharge checklist, g.) My

competence in discharge planning has improved. Specific numerical findings are found in the

appendix section.

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Table 2 (Outcome survey provided to participant following their participation with discharge

checklist):

Participant 1

Participant 2

Participant 3

Question

The qualitative questions were completed by participants (Appendix E) and further

discussed with the student researcher to collect additional information regarding the participants

and findings from utilizing the discharge checklist in practice. That data was divided into themes

and generalized into trends in order to assist the researcher to determine areas for edits to be

made for the second iteration of the discharge checklist. The theme found in the qualitative

survey for the first question of what worked well included the structure and organization of the

questions with the inclusion of open ended questions throughout discharge checklist. For the

second question, the summary of feedback for what did not work included the mini mental exam

and the specific checklist having too many pages impacted the therapist’s time management

during the evaluation. The majority of participants stated in their feedback for question three the

removal of the mini mental exam. And finally for the fourth question asked if anything was

missing from the checklist which all three participants discussed the formatting for some of the

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questions that only had a few options for answers, to actually include those answer options so the

therapist can check those boxes versus spending the time writing the information in.

Additionally, highlighted below is a unique piece of specific feedback from the

individual participants. Participant one stated having a physical discharge checklist was helpful

in order to provide continuity for every evaluation he or she completed which would match the

information collected from the other evaluating therapists. Participant two stated the perceived

value of using the open-ended questions as he or she is a tenured therapist so the checklist

provided a update to their approach to gather additional information from the patient. Lastly,

participant three suggested shortening the entire checklist and providing more opportunities to

limit the boxes to write in the answers and instead check the answers off. He or she also

discussed the challenge with time management when using the Mini Mental Exam and to remove

it entirely.

With all the feedback and findings provided, the first version of the discharge checklist

was updated to create a second iteration of the discharge checklist (Appendix K). This updated

version is available for future research to further analysis the implications to determine if this

iteration better aligns with the goals occupational therapists are trying to accomplish to increase

their competency and overall use of this tool during discharge planning.

Discussion

Following the evaluation for this capstone project, it was found that a discharge checklist

resulted in self reported higher clinical competency following the use of an intervention in

skilled nursing facilities discharging clients back to their prior home environment. This was

based on the overall findings through a pretest and posttest design, an outcomes survey using a

Likert scale, and a qualitative survey. This case study approach found anecdotal evidence that

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the discharge checklist benefitted three occupational therapists by providing a streamlined

discharge checklist to address potential barriers for clients returning to their home setting. These

findings relate to the literature from Tole and colleagues, (2016) who discussed how patients’

preparedness for discharge is improved through discharge interventions provided by professional

staff.

This case study approach supports more comprehensive assessment of the potential for a

discharge checklist in skilled nursing facilities. The descriptive data analysis supported that all

the participants increased their overall competency and comfort discharging patients using the

discharge checklist. The difference in scores from the pretest to posttest (Appendix L) further

supported the value of a consistent discharge checklist in a skilled nursing facility.

One limitation presented was small number of participants. There presents an

opportunity for an additional, more comprehensive assessment in future research addressing a

larger sample size. As a case study approach, the three participants provided the opportunity to

test the feasibility of the project, in hopes that future researchers are able to administer this

project with a larger group of participants to further expand the data collection.

Additionally, another barrier was the time frame. The timeframe of this capstone was one

semester from January through May. However a limitation on the timeframe was the IRB

process. The data collection began in April once IRB approval was received. This required a

change in the scope of the project from initially expecting to include a second iteration of this

revised discharge checklist in practice to creating the second iteration for future use. Following

the updates to the program, the opportunity presents next steps for future research to utilize the

second version of the discharge checklist (Appendix K) to further evaluate the discharge

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checklist’s feasibility and usability in clinical practice. Future researchers should utilize the

second version of the checklist with more participants from different skilled nursing facilities.

Lastly, in the data collection, there is the opportunity to include a section of interviews

from the patients participating to evaluate how the discharge checklist aligns with their goals to

discharge home. This would further support a patients centered approach. If the second version

provides continued assistance and value to the occupational therapists partaking in this study,

there is the opportunity to for a larger discussion for future research to implement this checklist

in multiple skilled nursing facilities across the country to address the ultimate outcome of

reducing hospital readmissions and improving quality care.

Conclusion

Utilizing a streamline discharge checklist in a SNF allow for occupational therapists to

discharge patients systematically and efficiently. During this capstone, a discharge checklist was

created and provided a systematic tool for evaluating occupational therapists to increase their

competency and collect streamlined, pertinent information prior to a patient discharging home.

This tool has shown increased self-reported competence and comfort through the discharge

process by occupational therapists resulting in overall better care provided by practitioners.

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Lescinskas, E., Stewart, D., & Shah, C. (2018). Improving Handoffs: Implementing a Training

Program for Incoming Internal Medicine Residents. Journal of graduate medical

education, 10(6), 698-701.

Levinson, D. R., & General, I. (2013). Skilled nursing facilities often fail to meet care planning

and discharge planning requirements. Washington, DC: US Department of Health and

Human Services, Office of the Inspector General.

Krause, J., Dias, L. P., Schedler, C., Krause, J., Dias, L. P., & Schedler, C. (2015). Competency-

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A DISCHARGE CHECKLIST

Appendix A

Discharge Checklist

This is a guide towards a structured discussion. Further discussion into aspects of the checklist

is recommended; however make sure all areas are addressed throughout the discussion with a

client.

Client Name & DOB:

Client’s subjective

explanation for reason of

admission:

Current Symptoms:

(additionally note

anything new)

Pain Level &

Description:

0 1 2 3 4 5 6 7 8 9 10

Previous therapies

received in hospital and

what was patient able to

do for themselves at the

hospital:

Mini Mental State Examination Score: ___

Previous Level of Function

Home Environment

[__] House [__] Apartment [__] Other:

Social and care support

(i.e. family members,

home health support)

Stairs

Enter front door:

Stairs based on levels in house:

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Handrails:

Location of bedroom

and bathroom (first floor

or multi level house?)

Describe the setup of

bathroom (tub/ walk in

shower, grab bars, DME)

Does the patient owns

any Durable Medical

Equipment

[__] wheelchair, [__] r/w, [__] shower chair, [__] BSC,

[__] grab bars, [__] hip kit,[__] weighted utensils, [__] other:

Previous completion of

ADLs and IADLs

(utilizing the Barthel

Index Scoring Form in

order to address ADLs

with added IADLs) and

note changes in physical

function/ new

limitations in the past 6

months

Feeding

Bathing

Grooming

Dressing

Bowels

Bladder

Toilet Use

Transfers

Mobility

Stairs

Cooking

Cleaning

Laundry

Describe visual or

hearing deficits

[__] Visual:

[__] Hearing:

Is the patient currently

managing his or her

own medicines?

Describe.

Expand on medicine

management system.

[__] Yes [__] No

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Recent history of falls or

hospitalizations prior to

most recent one?

Community mobility

(How did the client

previously get to

appointment(s) in order to

gather additional

functional limitations)

What does the patient

have to be able to do at

home when they return

and if their plan to

return home?

Expand on any

discharge barriers and

client’s current concerns

related to discharge.

Does the patient have

any follow up

appointments? Are

there any instructions or

precautions until the

follow up?

Are there any

anticipated discharge

barriers that should be

escalated to rehab

manager or social work

to address immediately

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Appendix B

Respondents rate their level of agreement with the following statements:

Measurement: 1-5 scale (1: strongly agree- 5: strongly disagree)

Pretest survey:

1.) I feel comfortable with recommending patients to be discharged back into the community

_____

2.) I am confident using a discharge checklist tool _____

3.) I am confident in identifying factors pertinent from a discharge checklist to provide an

effective discharge plan _____

4.) I am competent collecting the correct information in the beginning of discharge planning

_____

5.) I have a thorough process when collecting discharge planning information _____

6.) I collect the same information each time I discuss discharge planning in an initial evaluation

with a patient _____

Appendix C

Respondents rate their level of agreement with the following statements:

Measurement: 1-5 scale (1: strongly agree- 5: strongly disagree)

Posttest survey:

1.) I feel comfortable with recommending patients to be discharged back into the community

_____

2.) I am confident using a discharge checklist tool _____

3.) I am confident in identifying factors pertinent from a discharge checklist to provide an

effective discharge plan _____

4.) I am competent collecting the correct information in the beginning of discharge planning

_____

5.) I have a thorough process when collecting discharge planning information _____

6.) I collect the same information each time I discuss discharge planning in an initial evaluation

with a patient _____

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Appendix D

Outcome survey provided to participant following their participation with discharge checklist.

Measurement: 1-5 scale (1: strongly agree- 5: strongly disagree)

1.) The Discharge Checklist helped me improve my knowledge of how to:

a.) Identify risk factors prior to discharge

b.) Articulate goals of discharge planning

c.) Safely initiate discharge planning

d.) Safely modify discharge planning through a patient’s stay

2.) As a result of completing the discharge checklist, I am now more likely to:

a.) Use the discharge checklist in care of patients

3.) After completing the discharge checklist training

a.) I am confident in my ability to manage discharge planning

b.) I am capable of managing a discharge checklist throughout discharge planning

c.) I am able to provide thorough recommendations for patient to be discharged home

d.) I am able to meet the challenges of discharge planning for skilled nursing facility

patients

e.) My perception of my discharge planning knowledge has improved

f.) The discharge checklist has a positive impact on my use of discharge checklist

g.) My competence in discharge planning has improved

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Appendix E

Qualitative Questions

(1) What on the discharge checklist worked well?

(2) What on the discharge checklist did not work well and why?

(3) Is there anything on the checklist that is not needed and should be removed?

(4) Is there anything missing from the checklist? Then, the therapist will complete the

competency review.

Appendix F

Inputs:(Occupational(therapist,(clients,(literature(review,(

discharge(checklist,(time(for(training(and(implementation(

Activities:(Creation(of(discharge(checklist,(training(on(

utilizing(discharge(planning(checklist,(occupational(

therapist(utilizing(discharge(checklist(throughout(the(

discharge(process,(feedback,(edits(and(creation(of(second(

iteration(of(discharge(checklist(based(on(feedback((

Outputs:(Discharge(checklist,(education(on(use(of(

comprehensive(discharge(planning,(application(of(

discharge(planning(

Initial(Outcomes:(participation(in(discharge(checklist,(

occupational(therapist(able(to(follow(streamline(

discharge(plan(and(understand(the(value,(change(

clinician(competency((

Ultimate(Outcomes:(Streamline(discharge(planning(

checklist(created(to(lower(hospitalization(readmissions,(

increase(client(quality(of(life,(decreased(spending(for(CMS(

A DISCHARGE CHECKLIST

Appendix G

Appendix H

1( 2( 3( 4( 5( 6(

Participant)Rating)

Question)

Participant)1)

Pre(test(score(

Post(test(score(

1( 2( 3( 4( 5( 6(

Participant)Rating)

Question)

Participant)2)

Pre(test(score(

Post(test(score(

A DISCHARGE CHECKLIST

Appendix I

Appendix J

1( 2( 3( 4( 5( 6(

Participant)Rating)

Question)

Participant)3)

Pre(test(score(

Post(test(score(

A DISCHARGE CHECKLIST

Appendix K

Discharge Checklist

This is a guide towards a structured discussion. Further discussion into aspects of the checklist

is recommended; however make sure all areas are addressed throughout the discussion with a

client.

Client Name & DOB:

Client’s subjective

explanation for reason of

admission:

Current Symptoms:

(additionally note

anything new)

Pain Level &

Description:

0 1 2 3 4 5 6 7 8 9 10

Previous therapies

received in hospital and

what was patient able to

do for themselves at the

hospital:

[__] Therapy

[__] Stand

[__] Transfer to toilet

[__] Dress/ bathe

Previous Level of Function

Home Environment

[__] House [__] Apartment [__] Other:

Social and care support

(i.e. family members,

home health support)

Stairs

Enter front door:

Stairs based on levels in house:

Handrails:

Location of bedroom

and bathroom

[__] First floor

[__] Second floor

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[__] Other

Describe the setup of

bathroom

[__] Tub

[__] Walk in shower

[__] Grab bars

[__] DME

Does the patient owns

any Durable Medical

Equipment

[__] wheelchair, [__] r/w, [__] shower chair, [__] BSC,

[__] grab bars, [__] hip kit,[__] weighted utensils, [__] other:

Previous completion of

ADLs and IADLs

(utilizing the Barthel

Index Scoring Form in

order to address ADLs

with added IADLs) and

note changes in physical

function/ new

limitations in the past 6

months

Feeding

Bathing

Grooming

Dressing

Bowels

Bladder

Toilet Use

Transfers

Mobility

Stairs

Cooking

Cleaning

Laundry

Describe visual or

hearing deficits

[__] Visual:

[__] Hearing:

Is the patient currently

managing his or her

own medicines?

Describe.

Expand on medicine

management system.

[__] Yes [__] No

Recent history of falls or

hospitalizations prior to

A DISCHARGE CHECKLIST

most recent one?

Community mobility

(How did the client

previously get to

appointment(s) in order to

gather additional

functional limitations)

What does the patient

have to be able to do at

home when they return

and if their plan to

return home?

Expand on any

discharge barriers and

client’s current concerns

related to discharge.

Does the patient have

any follow up

appointments? Are

there any instructions or

precautions until the

follow up?

Are there any

anticipated discharge

barriers that should be

escalated to rehab

manager or social work

to address immediately

A DISCHARGE CHECKLIST

Appendix L

Participant)

Question)

Pretest)

score)

Posttest)

score)

Difference)