Subinternship Medicine · Year 4 · from Subinternship Medicine
Case 3: Complex Discharge to Skilled Nursing Facility
Clinical Image
Source: Wikimedia Commons - Physical Therapy - CC BY-SA 4.0
Case Presentation
An 82-year-old man who lives alone is hospitalized with a hip fracture after a fall. He undergoes ORIF and has an uncomplicated surgical course. Pre-hospitalization, he was independent in ADLs, used a cane, and drove himself to appointments. Post-operatively, physical therapy assesses him and finds he requires maximal assist for transfers and cannot bear weight on the operative leg for 6 weeks. Occupational therapy notes he cannot safely prepare meals or bathe independently. He is clearly not safe to return home alone. The case manager discusses disposition options: acute rehabilitation versus subacute/SNF rehabilitation. Given his age and that he cannot tolerate 3 hours of therapy daily (required for acute rehab), subacute rehabilitation at a skilled nursing facility is recommended. The sub-intern prepares a comprehensive discharge summary including: diagnosis and procedure, surgical details and precautions (weight-bearing status, DVT prophylaxis with enoxaparin for 4 weeks), pending items (2-week follow-up radiograph, staple removal at 2 weeks), medications with specific attention to anticoagulation and pain management plan (scheduled acetaminophen, oxycodone PRN with specific quantity and tapering expectation), code status (Full Code, previously discussed), and specific therapy goals for SNF. She contacts the accepting SNF directly to verbally review the case, emphasizing the weight-bearing restriction and anticoagulation needs. The patient successfully completes 3 weeks of SNF rehabilitation and returns home with outpatient PT.
Key Learning Points
- Disposition options must match patient needs: home alone (for independent patients), home with services (for those needing some assistance), acute rehab (for those tolerating 3+ hours therapy daily), or SNF/subacute rehab (for moderate therapy needs or those not tolerating intensive therapy)
- Discharge summaries should be transmitted within 24-48 hours and include diagnosis, hospital course, medication changes, pending items, and specific follow-up needs
- Direct communication (phone call) with accepting facilities ensures critical information is transmitted, especially for complex patients or high-risk items
- Specific information for SNF: weight-bearing status, DVT prophylaxis plan, wound care needs, PT/OT goals, anticipated length of stay, and post-SNF follow-up plans